Provider Demographics
NPI:1932376886
Name:FOWLER MEDICAL CLINIC
Entity Type:Organization
Organization Name:FOWLER MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-884-1330
Mailing Address - Street 1:801 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FOWLER
Mailing Address - State:IN
Mailing Address - Zip Code:47944-1568
Mailing Address - Country:US
Mailing Address - Phone:765-884-1330
Mailing Address - Fax:
Practice Address - Street 1:801 E 5TH ST
Practice Address - Street 2:
Practice Address - City:FOWLER
Practice Address - State:IN
Practice Address - Zip Code:47944-1568
Practice Address - Country:US
Practice Address - Phone:765-884-1330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0131474261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN390690OtherMEDICARE
IN200085460Medicaid
IN100142830Medicaid
IN200085460Medicaid