Provider Demographics
NPI:1811003635
Name:BOWDEN, PHILLIP R (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:R
Last Name:BOWDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3634
Mailing Address - Country:US
Mailing Address - Phone:901-272-7200
Mailing Address - Fax:901-260-5916
Practice Address - Street 1:1417 MONROE AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3634
Practice Address - Country:US
Practice Address - Phone:901-272-7200
Practice Address - Fax:901-260-5916
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25950174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3088251Medicaid
TN25950OtherMEDICAL LICENSE NUMBER
TNB90012Medicare UPIN
TN25950OtherMEDICAL LICENSE NUMBER