Provider Demographics
NPI:1336143965
Name:BOUWENS, ERIC C (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:C
Last Name:BOUWENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 GRANDVILLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4920
Mailing Address - Country:US
Mailing Address - Phone:616-685-8400
Mailing Address - Fax:616-742-1322
Practice Address - Street 1:1900 44TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5008
Practice Address - Country:US
Practice Address - Phone:616-685-8500
Practice Address - Fax:616-685-8075
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1336143965Medicaid
MIMI3233485Medicare PIN
MIC39435Medicare UPIN