Healthcare Provider Details

I. General information

NPI: 1972936805
Provider Name (Legal Business Name): BOWDON FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 W COLLEGE ST
BOWDON GA
30108-1309
US

IV. Provider business mailing address

307 W COLLEGE ST
BOWDON GA
30108-1309
US

V. Phone/Fax

Practice location:
  • Phone: 770-328-2006
  • Fax:
Mailing address:
  • Phone: 770-328-2006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN 141751
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number65367
License Number StateGA

VIII. Authorized Official

Name: MR. ROBERT C SALTER
Title or Position: NURSE PRACTITIONER
Credential: MSN,CRNP
Phone: 770-328-2006