Basic Information
| Provider Information | |||||||||
| NPI: | 1992766190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOWMAN-MARSH | ||||||||
| FirstName: | JAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 708850 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840708850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668692397 | ||||||||
| FaxNumber: | 8013529502 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 W DEYOUNG ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629595884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189987492 | ||||||||
| FaxNumber: | 6189987493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 05/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036076429 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036076429 | 01 | IL | BCBS | OTHER | 036076429 | 05 | IL | MEDICAID | P00172788 | 01 | IL | RAIL ROAD MEDICARE | OTHER |