=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235110883
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY POWERS ROVEDA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2005
-----------------------------------------------------
Last Update Date | 05/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2451 FILLINGIM STREET
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36617-2238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-471-7790
-----------------------------------------------------
Fax | 251-471-7715
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 40480
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36640-0480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-471-7790
-----------------------------------------------------
Fax | 251-471-7715
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZC0006X
-----------------------------------------------------
Taxonomy Name | Clinical Pathology Physician
-----------------------------------------------------
License Number | 16954
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0105X
-----------------------------------------------------
Taxonomy Name | Clinical Pathology/Laboratory Medicine Physician
-----------------------------------------------------
License Number | 16954
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------