Healthcare Provider Details

I. General information

NPI: 1154888048
Provider Name (Legal Business Name): BOWIE STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14000 JERICHO PARK ROAD HENRY WISE WELLNESS CENTER, CMRC, LOWER LEVEL
BOWIE MD
20715
US

IV. Provider business mailing address

14000 JERICHO PARK ROAD HENRY WISE WELLNESS CENTER, CMRC, LOWER LEVEL
BOWIE MD
20715
US

V. Phone/Fax

Practice location:
  • Phone: 301-860-4170
  • Fax: 601-860-4179
Mailing address:
  • Phone: 301-860-4170
  • Fax: 601-860-4179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. ARTIE LEE TRAVIS
Title or Position: VICE PRESIDENT STUDENT AFFAIRS
Credential: ED.D.
Phone: 301-860-3390