Basic Information
| Provider Information | |||||||||
| NPI: | 1255316691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOWERS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487640779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893620153 | ||||||||
| FaxNumber: | 9893624683 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HEMLOCK | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893620153 | ||||||||
| FaxNumber: | 9893624683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 05/23/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 5101015455 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 310981343A | 05 | GA | MEDICAID | 310981343F | 05 | GA | MEDICAID | G59129 | 05 | SC | MEDICAID | 310981343C | 05 | GA | MEDICAID | 310981343E | 05 | GA | MEDICAID | 310981343D | 05 | GA | MEDICAID | 4709960 | 05 | MI | MEDICAID | 01052278 | 01 | GA | AMERIGROUP | OTHER | 310981343B | 05 | GA | MEDICAID |