Healthcare Provider Details

I. General information

NPI: 1225072242
Provider Name (Legal Business Name): JOHN A. POWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 S BRENTWOOD BLVD STE.1160
RICHMOND HEIGHTS MO
63117-1223
US

IV. Provider business mailing address

1034 S BRENTWOOD BLVD STE.1160
RICHMOND HEIGHTS MO
63117-1223
US

V. Phone/Fax

Practice location:
  • Phone: 314-863-7080
  • Fax: 314-863-1540
Mailing address:
  • Phone: 314-863-7080
  • Fax: 314-863-1540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberR6721
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: