Provider Demographics
NPI:1972936805
Name:BOWDON FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:BOWDON FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:SALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MSN,CRNP
Authorized Official - Phone:770-328-2006
Mailing Address - Street 1:307 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BOWDON
Mailing Address - State:GA
Mailing Address - Zip Code:30108-1309
Mailing Address - Country:US
Mailing Address - Phone:770-328-2006
Mailing Address - Fax:
Practice Address - Street 1:307 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BOWDON
Practice Address - State:GA
Practice Address - Zip Code:30108-1309
Practice Address - Country:US
Practice Address - Phone:770-328-2006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65367207Q00000X
GARN 141751363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALS84259Medicare UPIN