Healthcare Provider Details

I. General information

NPI: 1386349934
Provider Name (Legal Business Name): ANNALISE MARIE BOWEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MICHIGAN ST NE FL 8
GRAND RAPIDS MI
49503-2531
US

IV. Provider business mailing address

275 MICHIGAN ST NE FL 8
GRAND RAPIDS MI
49503-2531
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-8810
  • Fax:
Mailing address:
  • Phone: 616-391-8810
  • Fax: 616-391-8897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351051084
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: