Healthcare Provider Details

I. General information

NPI: 1518397215
Provider Name (Legal Business Name): BRENT J BOWEN M.D. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 S 250 E STE 235
MURRAY UT
84107-6191
US

IV. Provider business mailing address

PO BOX 57547
SALT LAKE CITY UT
84157-0547
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-5115
  • Fax:
Mailing address:
  • Phone: 801-314-2362
  • Fax: 801-314-5117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2736038905
License Number StateUT

VIII. Authorized Official

Name: DR. BRENT JAMES BOWEN
Title or Position: OWNER
Credential: M.D.
Phone: 801-314-2362