Healthcare Provider Details

I. General information

NPI: 1053491845
Provider Name (Legal Business Name): MARY E POWELL ST LOUIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 SAYBROOK RD SUITE 100
MIDDLETOWN CT
06457-4788
US

IV. Provider business mailing address

512 SAYBROOK RD SUITE 100
MIDDLETOWN CT
06457-4788
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-7636
  • Fax: 860-894-1882
Mailing address:
  • Phone: 860-347-7636
  • Fax: 860-894-1882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036668
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: