Basic Information
| Provider Information | |||||||||
| NPI: | 1629032594 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | RANDELL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 NW 49TH ST STE 125 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547636655 | ||||||||
| FaxNumber: | 9547636799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 S ANDREWS AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547636655 | ||||||||
| FaxNumber: | 9547636799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | ME50450 | FL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 270228200 | 05 | FL | MEDICAID | 03726 | 01 | FL | BCBS | OTHER |