Provider Demographics
NPI:1922110238
Name:BOWMAN, GLEN (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:BOWMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W THOMAS RD # 301
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4407
Mailing Address - Country:US
Mailing Address - Phone:602-406-6238
Mailing Address - Fax:
Practice Address - Street 1:350 W THOMAS RD
Practice Address - Street 2:ATTN: BNI SURGICAL SUITE
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013
Practice Address - Country:US
Practice Address - Phone:602-406-3541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG185046207L00000X
UT319122-1205207L00000X
AZ73631207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTTPRA09326OtherMOLINA
UT2090168OtherUNITED HEALTHCARE
UT107028042101OtherIHC
UT77515OtherPEHP
ID806868300Medicaid
UT851001OtherDESERET MUTUAL
AZ858409Medicaid
NV100503208Medicaid
WY119647200Medicaid
UT1502954OtherUMWA
UTQM0000075886OtherALTIUS
UT835388OtherHEALTHY U
UT870545614BOWOtherEDUCATORS MUTUAL
UT835388OtherHEALTHY U
UT055327133Medicare ID - Type Unspecified
UTH08342Medicare UPIN