Healthcare Provider Details

I. General information

NPI: 1144269648
Provider Name (Legal Business Name): ELLEN K BOWLIN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 W MARKET ST
LIMA OH
45801-4602
US

IV. Provider business mailing address

4750 HEMPSTEAD STATION DR
KETTERING OH
45429-5164
US

V. Phone/Fax

Practice location:
  • Phone: 419-227-3361
  • Fax: 419-226-9826
Mailing address:
  • Phone: 800-875-0136
  • Fax: 937-619-4231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50002051
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier292707100
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: