Basic Information
| Provider Information | |||||||||
| NPI: | 1053653519 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOWMAN | ||||||||
| FirstName: | CAITLIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 438 ADAM SHEPHERD PARKWAY SUITE 1 | ||||||||
| Address2: | |||||||||
| City: | SHEPHERDSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401651622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025431055 | ||||||||
| FaxNumber: | 5025431052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2013 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 49862 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 49862 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | K202040 | 01 | KY | KY MEDICARE PTAN | OTHER | 7100308410 | 05 | KY | MEDICAID |