Healthcare Provider Details

I. General information

NPI: 1023309580
Provider Name (Legal Business Name): PAUL BOWN MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4513 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1408
US

IV. Provider business mailing address

4513 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1408
US

V. Phone/Fax

Practice location:
  • Phone: 304-768-7371
  • Fax: 304-720-3628
Mailing address:
  • Phone: 304-768-7371
  • Fax: 304-720-3628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number20411
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20411
License Number StateWV

VIII. Authorized Official

Name: PAUL C. BOWN
Title or Position: OWNER
Credential: MD
Phone: 304-768-7371