1972615920 NPI number — JEREMY S BOWEN P.A.

Table of content: JEREMY S BOWEN P.A. (NPI 1972615920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972615920 NPI number — JEREMY S BOWEN P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOWEN
Provider First Name:
JEREMY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
M

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:
1972615920
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12860 TROXLER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLAND
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62249-2898
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-651-2810
Provider Business Mailing Address Fax Number:
618-651-0077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12860 TROXLER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGHLAND
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62249-2898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-651-2810
Provider Business Practice Location Address Fax Number:
618-651-0077
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CK7203 . This is a "RR GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 207988 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P019009721 . This is a "BLUE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P00365761 . This is a "RR MEDICARE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: PA0495 . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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