MEDICARE: LENNON E. BOWEN IV M.D.

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	2084N0600X	Clinical Neurophysiology Physician	18586	MS
2	2084N0400X	Neurology Physician	18586	MS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00280787	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	646000515	OTHER		COMMERCIAL
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619919156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LENNON E. BOWEN IV M.D.

Provider Business Mailing Address
First Line	:	6300 E LAKE BLVD STE 301
Second Line	:
City	:	VANCLEAVE
State	:	MS
Zip	:	39565-6771
Country	:	US
Telephone Number	:	228-230-2663
Fax Number	:	228-206-1192

Provider Business Practice Location Address
First Line	:	6300 E LAKE BLVD STE 201
Second Line	:
City	:	VANCLEAVE
State	:	MS
Zip	:	39565
Country	:	US
Telephone Number	:	228-230-2663
Fax Number	:	228-206-1192

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

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	12/14/2018

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Directions to “ LENNON E. BOWEN IV M.D.” Practice Location

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