Provider Demographics
NPI:1760521140
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 1:1535 PROVIDENT DR.
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580
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:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN423-0-PIP273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000202972OtherBLUE CROSS PROVIDER ID
IN000000202972OtherBLUE CROSS PROVIDER ID