Healthcare Provider Details

I. General information

NPI: 1568623569
Provider Name (Legal Business Name): JASON ALLEN POWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-6511
US

IV. Provider business mailing address

MEDICAL CENTER BLVD PROVIDER ENROLLMENT
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2255
  • Fax:
Mailing address:
  • Phone: 336-716-2255
  • Fax: 336-716-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License NumberME115630
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2014-01064
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: