Provider Demographics
NPI:1386752251
Name:POWELL, CAROLINE KELLER (MD)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:KELLER
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR STE 320
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6896
Practice Address - Country:US
Practice Address - Phone:803-434-6771
Practice Address - Fax:803-434-3955
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26823207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC268231Medicaid
SC268231Medicaid
SCAA0546Medicare ID - Type Unspecified
SCAA0546 2603Medicare PIN
SCAA05467579Medicare PIN