Provider Demographics
NPI:1639172810
Name:THE OTIS R BOWEN CENTER FOR HUMAN SERVICES INC
Entity Type:Organization
Organization Name:THE OTIS R BOWEN CENTER FOR HUMAN SERVICES INC
Other - Org Name:OTIS R BOWEN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP FISCAL DIVISION
Authorized Official - Prefix:MR
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:ATTN: ANNE LAWSON - PERFORMANCE IMPROVEMENT
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 1:850 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3163
Practice Address - Country:US
Practice Address - Phone:574-267-7169
Practice Address - Fax:574-269-3995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN4230CMHC261QM0850X, 261QM0855X
IN4231PIP283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCB5225OtherRAILROAD MEDICARE
IN452270OtherMEDICARE
IN100273680AMedicaid
IN100428290AMedicaid
IN169430OtherMEDICARE
INCH1896OtherRAILROAD MEDICARE
IN452280OtherMEDICARE
IN000000202972OtherANTHEM BLUE CROSS BLUE SHIELD
IN100156770Medicaid
IN100428290AMedicaid
IN452270OtherMEDICARE