=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447362066
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAROLD JONATHAN BOWERSOX D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 02/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9500 MENTOR AVE SUITE 360
-----------------------------------------------------
City | MENTOR
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44060-8713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-255-5508
-----------------------------------------------------
Fax | 440-357-4416
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 714328
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43271-4328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-354-1899
-----------------------------------------------------
Fax | 440-354-1845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 34-003486
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------