Provider Demographics
NPI:1609047083
Name:BOWLING GREEN DERMATOLOGY & SKIN CANCER SPECIALISTS PLLC
Entity Type:Organization
Organization Name:BOWLING GREEN DERMATOLOGY & SKIN CANCER SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:COWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-672-5953
Mailing Address - Street 1:1106 FAIRWAY STREET
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103
Mailing Address - Country:US
Mailing Address - Phone:615-672-5953
Mailing Address - Fax:615-672-5953
Practice Address - Street 1:1106 FAIRWAY STREET
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103
Practice Address - Country:US
Practice Address - Phone:615-672-5953
Practice Address - Fax:615-672-5953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41690207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00663Medicare PIN