Provider Demographics
NPI:1144432402
Name:POWELL, BRIAN KEITH (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:POWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10549
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-0549
Mailing Address - Country:US
Mailing Address - Phone:727-824-8181
Mailing Address - Fax:
Practice Address - Street 1:12420 130TH AVE
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-1919
Practice Address - Country:US
Practice Address - Phone:727-824-8181
Practice Address - Fax:727-587-7739
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016675207Q00000X
FLOS12134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080G310660OtherBCBS OF MICHIGAN
381908328-435OtherCARE SOURCE OF MICHIGAN
MI1144432402Medicaid
381908328OtherPRIORITY HEALTH OF MICHIGAN
176125OtherGREAT LAKES HEALTH PLAN OF MI
01019633OtherHEALTH PLUS OF MICHIGAN
080G310660OtherBLUE CARE NETWORK OF MICHIGAN
FL008859000Medicaid
1053717OtherMCLAREN HEALTH PLAN/HEALTH ADVANTAGE
1144432402OtherMOLINA HEALTHCARE OF MICHIGAN
381908328OtherAETNA UNDER
54684OtherHEALTH PLAN OF MICHIGAN