Provider Demographics
NPI:1649263500
Name:COWAN, BENNETT Y JR (MD)
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:Y
Last Name:COWAN
Suffix:JR
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 1:271 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7455
Mailing Address - Country:US
Mailing Address - Phone:423-968-2311
Mailing Address - Fax:423-968-2312
Practice Address - Street 1:271 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7455
Practice Address - Country:US
Practice Address - Phone:423-968-2311
Practice Address - Fax:423-968-2312
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000009364207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3001112Medicaid
TN3001112Medicaid
TN3001110Medicare PIN
TNC47601Medicare UPIN
TN3001115Medicare ID - Type Unspecified