Basic Information
| Provider Information | |||||||||
| NPI: | 1992824007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | ANGUS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 WELLS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320732982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042826331 | ||||||||
| FaxNumber: | 9046191080 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 RIVERSIDE AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322058233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042657755 | ||||||||
| FaxNumber: | 9042657754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | OS10548 | FL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208VP0014X | OS 10548 | FL | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 2081P2900X | OS10548 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001324200 | 05 | FL | MEDICAID |