Provider Demographics
NPI:1568824902
Name:BOWERS, AMANDA C (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:C
Last Name:BOWERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:C
Other - Last Name:WORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:70 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-3098
Mailing Address - Country:US
Mailing Address - Phone:781-631-7800
Mailing Address - Fax:781-631-4319
Practice Address - Street 1:70 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-3098
Practice Address - Country:US
Practice Address - Phone:781-631-7800
Practice Address - Fax:781-631-4319
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA279201208000000X
MEMD23166208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMD23166OtherSTATE LICENSE
MAMCSR005248AOtherMCSR
14523875OtherCAQH
MA279201OtherSTATE LICENSE
VT042.0014718OtherSTATE LICENSE
1470576OtherAAP
1015844OtherABP
PA470641OtherSTATE LICENSE