Provider Demographics
NPI:1710152228
Name:BRENT J. BOWEN, M.D.P.C.
Entity Type:Organization
Organization Name:BRENT J. BOWEN, M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:FORBES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-314-2362
Mailing Address - Street 1:5250 COMMERCE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7926
Mailing Address - Country:US
Mailing Address - Phone:801-314-2362
Mailing Address - Fax:801-314-2413
Practice Address - Street 1:5250 COMMERCE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-7926
Practice Address - Country:US
Practice Address - Phone:801-314-2362
Practice Address - Fax:801-314-2413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT173000000X173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000012047Medicare UPIN