1457318438 NPI number — KENDRA D BOWEN PAC

Table of content: KENDRA D BOWEN PAC (NPI 1457318438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457318438 NPI number — KENDRA D BOWEN PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOWEN
Provider First Name:
KENDRA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

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:
1457318438
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1441 W BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRALIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62801-5613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-532-9050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1441 W BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62801-5613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-532-9050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2006

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: 363AS0400X , with the licence number:  010234 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 085003158 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00469189 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 208959 . This is a "MED GRP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CE9335 . This is a "RR GROUP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 207988 . This is a "MED GROUP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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