MEDICARE: DR. DARRELL JACK POTTER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	2006-01651	NC
2	207X00000X	Orthopaedic Surgery Physician	MD-42830	IA
3	207X00000X	Orthopaedic Surgery Physician	2016005465	MO
4	207X00000X	Orthopaedic Surgery Physician	4301030727	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51041005	OTHER	AL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265412605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DARRELL JACK POTTER M.D.

Provider Business Mailing Address
First Line	:	6214 SWEET CLOVER LN SE
Second Line	:
City	:	CALEDONIA
State	:	MI
Zip	:	49316-8291
Country	:	US
Telephone Number	:	334-322-3489
Fax Number	:

Provider Business Practice Location Address
First Line	:	5491 W ROSEBUD CT SE
Second Line	:	#4
City	:	KENTWOOD
State	:	MI
Zip	:	49512-9464
Country	:	US
Telephone Number	:	334-322-3489
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	11/03/2019

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