Basic Information
| Provider Information | |||||||||
| NPI: | 1518397215 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRENT J BOWEN M.D. P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRENT J BOWEN, M.D. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 57547 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841570547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013142362 | ||||||||
| FaxNumber: | 8013145117 | ||||||||
| Practice Location | |||||||||
| Address1: | 5770 S 250 E STE 235 | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841076191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013145115 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2013 | ||||||||
| LastUpdateDate: | 11/15/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOWEN | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8013142362 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081S0010X | 2736038905 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1710152228 | 01 | UT | MEDICARE NPI | OTHER | 1780644054 | 01 | UT | PROVIDER NPI | OTHER |