Healthcare Provider Details

I. General information

NPI: 1306282785
Provider Name (Legal Business Name): MATTHEW POWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S EUCLID AVE MSC 8116-0043-08
ST. LOUIS MO
63110-1010
US

IV. Provider business mailing address

660 S EUCLID AVE MSC 8116-0043-08
ST. LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-4569
  • Fax: 314-454-2561
Mailing address:
  • Phone: 314-454-4569
  • Fax: 314-454-2561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9408066
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2025023110
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: