Healthcare Provider Details

I. General information

NPI: 1821939786
Provider Name (Legal Business Name): PETER JACKSON BOWLING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WASHINGTON ST
BOSTON MA
02111-1552
US

IV. Provider business mailing address

800 WASHINGTON ST
BOSTON MA
02111-1552
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6044
  • Fax:
Mailing address:
  • Phone: 617-636-6044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number3020484
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: