Basic Information
| Provider Information | |||||||||
| NPI: | 1609976927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOWERS | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOWERS | ||||||||
| OtherFirstName: | TAMARA | ||||||||
| OtherMiddleName: | MCVAY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 50 N PERRY ST | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483422217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483385516 | ||||||||
| FaxNumber: | 2483385547 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 N PERRY ST | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483385516 | ||||||||
| FaxNumber: | 2483385547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 5101015454 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 059128 | GA | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 598549056E | 05 | GA | MEDICAID | 01057454 | 01 | GA | AMERIGROUP | OTHER | 598549056B | 05 | GA | MEDICAID | 598549056C | 05 | GA | MEDICAID | 598549056A | 05 | GA | MEDICAID | 598549056G | 05 | GA | MEDICAID | 598549056 | 05 | GA | MEDICAID | G59128 | 05 | SC | MEDICAID | 598549056D | 05 | GA | MEDICAID |