Provider Demographics
NPI:1437207156
Name:OTIS R. BOWEN CENTER
Entity Type:Organization
Organization Name:OTIS R. BOWEN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FISCAL DIVISION
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAUMGARTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-267-7169
Mailing Address - Street 1:850 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3163
Mailing Address - Country:US
Mailing Address - Phone:574-267-7169
Mailing Address - Fax:574-269-3995
Practice Address - Street 1:255 N MIAMI ST
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-2705
Practice Address - Country:US
Practice Address - Phone:260-563-8446
Practice Address - Fax:260-563-1902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN423-0-CMHC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN941450Medicare ID - Type UnspecifiedMEDICAID ID#