Provider Demographics
NPI:1053407809
Name:POWELL, MELISSA A (MD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:A
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6971
Mailing Address - Country:US
Mailing Address - Phone:423-431-2477
Mailing Address - Fax:423-431-2478
Practice Address - Street 1:410 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 130
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6971
Practice Address - Country:US
Practice Address - Phone:423-431-2477
Practice Address - Fax:423-431-2478
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16746208600000X
TN31797208600000X, 2086S0102X
VA01012363662086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053407809Medicaid
NC1053407809Medicaid
WV3004661000Medicaid
WVP00358617OtherRAILROAD MEDICARE
TNQ002848Medicaid
TN3709285Medicare UPIN
WVPO6033711Medicare PIN
VA1053407809Medicaid
G59584Medicare UPIN