Healthcare Provider Details

I. General information

NPI: 1235110883
Provider Name (Legal Business Name): KELLY POWERS ROVEDA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY KELLY POWERS

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 FILLINGIM STREET
MOBILE AL
36617-2238
US

IV. Provider business mailing address

PO BOX 40480
MOBILE AL
36640-0480
US

V. Phone/Fax

Practice location:
  • Phone: 251-471-7790
  • Fax: 251-471-7715
Mailing address:
  • Phone: 251-471-7790
  • Fax: 251-471-7715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number16954
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number16954
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: