Healthcare Provider Details

I. General information

NPI: 1093047185
Provider Name (Legal Business Name): TERRY D POWELL RADIATION ONCOLOGIST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2010
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W 4TH ST, RADIATION ONCOLOGY DEPT
COFFEYVILLE KS
67337
US

IV. Provider business mailing address

PO BOX 993
COFFEYVILLE KS
67337-0993
US

V. Phone/Fax

Practice location:
  • Phone: 620-252-1684
  • Fax: 620-252-1692
Mailing address:
  • Phone: 620-252-1684
  • Fax: 620-252-1692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number9106
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number04-14232
License Number StateKS

VIII. Authorized Official

Name: TERRY DOUGLAS POWELL
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 620-252-1684