Provider Demographics
NPI:1902023559
Name:RICKY D BOWLIN, MD LLC
Entity Type:Organization
Organization Name:RICKY D BOWLIN, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOWLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-548-5114
Mailing Address - Street 1:130 WEST MARTZ STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331
Mailing Address - Country:US
Mailing Address - Phone:937-548-5114
Mailing Address - Fax:
Practice Address - Street 1:130 WEST MARTZ STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331
Practice Address - Country:US
Practice Address - Phone:937-548-5114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35066556207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2208211Medicaid
RI9343941Medicare ID - Type Unspecified
OH2208211Medicaid