1366550030 NPI number — DR. GRACE ELAINE FOWLER DO

Table of content: DR. GRACE ELAINE FOWLER DO (NPI 1366550030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366550030 NPI number — DR. GRACE ELAINE FOWLER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOWLER
Provider First Name:
GRACE
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOWLER
Provider Other First Name:
GRACE
Provider Other Middle Name:
ELAINE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1366550030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VINCENNES
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47591-0030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-882-5524
Provider Business Mailing Address Fax Number:
812-882-5525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
626 PRAIRE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VINCENNES
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47591-1060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-882-5524
Provider Business Practice Location Address Fax Number:
812-882-5525
Provider Enumeration Date:
08/25/2006

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: 207R00000X , with the licence number:  02003008A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 02003008A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200391740A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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