1619390622 NPI number — LAURENCE R BOWER III MD

Table of content: (NPI 1619390622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619390622 NPI number — LAURENCE R BOWER III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAURENCE R BOWER III MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619390622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19A GRUENE PARK DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRAUNFELS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78130-2459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-632-7562
Provider Business Mailing Address Fax Number:
830-632-6793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 W BANDERA ROAD #4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOERNE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-331-0610
Provider Business Practice Location Address Fax Number:
830-331-1042
Provider Enumeration Date:
01/27/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOWER
Authorized Official First Name:
LAURENCE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
830-331-0125

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  J8926 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1659478303 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8EE312 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 157938501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".