MEDICARE: DR. KENNETH ANGUS POWELL D.O.

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	208100000X	Physical Medicine & Rehabilitation Physician	OS10548	FL
2	208VP0014X	Interventional Pain Medicine Physician	OS 10548	FL
3	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	OS10548	FL

Other Identifiers

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

General Provider Information

NPI Number	:	1992824007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH ANGUS POWELL D.O.

Provider Business Mailing Address
First Line	:	705 WELLS RD STE 300
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-2982
Country	:	US
Telephone Number	:	904-282-6331
Fax Number	:	904-619-1080

Provider Business Practice Location Address
First Line	:	2700 RIVERSIDE AVE STE 2
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-8233
Country	:	US
Telephone Number	:	904-265-7755
Fax Number	:	904-265-7754

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

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	08/31/2022

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