Basic Information
| Provider Information | |||||||||
| NPI: | 1891707642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 526 | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420250526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705272411 | ||||||||
| FaxNumber: | 2705278734 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 OLD SYMSONIA RD | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420255094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705272411 | ||||||||
| FaxNumber: | 2705278734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34554 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2705272411 | 01 | OFFICE PHONE | OTHER | 34554 | 01 | KY | KY STATE LIC | OTHER | 64345648 | 05 | KY | MEDICAID | 4047220 | 05 | TN | MEDICAID |