MEDICARE: ERIC C BOUWENS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301057167	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336143965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC C BOUWENS MD

Provider Business Mailing Address
First Line	:	730 GRANDVILLE AVE SW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4920
Country	:	US
Telephone Number	:	616-685-8400
Fax Number	:	616-742-1322

Provider Business Practice Location Address
First Line	:	1900 44TH ST SE
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49508-5008
Country	:	US
Telephone Number	:	616-685-8500
Fax Number	:	616-685-8075

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	06/10/2015

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