1174611453 NPI number — HAROLD J. BOWERSOX, D.O., INC

Table of content: (NPI 1174611453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174611453 NPI number — HAROLD J. BOWERSOX, D.O., INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAROLD J. BOWERSOX, D.O., INC
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:
1174611453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34950 CHARDON RD
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
WILLOUGHBY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44094-9162
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-602-7700
Provider Business Mailing Address Fax Number:
440-602-9540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34950 CHARDON ROAD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
WILLOUGHBY HILLS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-602-7700
Provider Business Practice Location Address Fax Number:
440-602-9540
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOWERSOX
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
JONATHAN
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
440-602-7700

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2731422 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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