Provider Demographics
NPI:1922171057
Name:BOWDLE CLINIC
Entity Type:Organization
Organization Name:BOWDLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-285-6146
Mailing Address - Street 1:P.O. BOX 556
Mailing Address - Street 2:
Mailing Address - City:BOWDLE
Mailing Address - State:SD
Mailing Address - Zip Code:57428-0556
Mailing Address - Country:US
Mailing Address - Phone:605-285-6146
Mailing Address - Fax:605-285-6410
Practice Address - Street 1:8001 WEST 5TH STREET
Practice Address - Street 2:
Practice Address - City:BOWDLE
Practice Address - State:SD
Practice Address - Zip Code:57428
Practice Address - Country:US
Practice Address - Phone:605-285-6832
Practice Address - Fax:605-285-6986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDCK9117Medicare ID - Type UnspecifiedRR MEDICARE PROVIDER #