Provider Demographics
NPI:1205036233
Name:MAIN ST. MEDICAL CENTER OF VIDOR
Entity Type:Organization
Organization Name:MAIN ST. MEDICAL CENTER OF VIDOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DUNCAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-769-0237
Mailing Address - Street 1:1091 N MAIN ST
Mailing Address - Street 2:STE B
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-4339
Mailing Address - Country:US
Mailing Address - Phone:409-769-0237
Mailing Address - Fax:409-769-0254
Practice Address - Street 1:1091 N MAIN ST
Practice Address - Street 2:STE B
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-4339
Practice Address - Country:US
Practice Address - Phone:409-769-0237
Practice Address - Fax:409-769-0254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMDE9547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00298682OtherRAILROAD MEDICARE
TX0017MHOtherBCBS
TXB21428Medicare UPIN