Healthcare Provider Details

I. General information

NPI: 1699777029
Provider Name (Legal Business Name): JOHN R POWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S MANNING BLVD 0203 MCAULEY
ALBANY NY
12208-1707
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-525-1550
  • Fax: 518-525-6545
Mailing address:
  • Phone: 518-525-5634
  • Fax: 518-649-4094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number231657
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number231657
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: