Healthcare Provider Details

I. General information

NPI: 1902858244
Provider Name (Legal Business Name): MATTHEW G. POWERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 S UTICA AVE SJMC RADIOLOGY
TULSA OK
74104-6520
US

IV. Provider business mailing address

DEPARTMENT 814
TULSA OK
74182-0001
US

V. Phone/Fax

Practice location:
  • Phone: 918-744-2171
  • Fax: 918-744-3137
Mailing address:
  • Phone: 918-748-4378
  • Fax: 918-743-6542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number12621
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number12621
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number12621
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: