Healthcare Provider Details

I. General information

NPI: 1104818582
Provider Name (Legal Business Name): PHILIP B BOVELL, MDPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11701 LIVINGSTON RD STE 204
FORT WASHINGTON MD
20744-5104
US

IV. Provider business mailing address

11701 LIVINGSTON RD STE 204
FORT WASHINGTON MD
20744-5104
US

V. Phone/Fax

Practice location:
  • Phone: 301-292-0757
  • Fax:
Mailing address:
  • Phone: 301-292-0757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberD0020121
License Number StateMD

VIII. Authorized Official

Name: MR. PHILIP BENJAMIN BOVELL
Title or Position: OWNER
Credential: MD
Phone: 301-292-0757