Basic Information
| Provider Information | |||||||||
| NPI: | 1346278835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOWMAN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | DUANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11995 SINGLETREE LN STE 500 | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553445349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525951301 | ||||||||
| FaxNumber: | 6122944903 | ||||||||
| Practice Location | |||||||||
| Address1: | 11995 SINGLETREE LN STE 500 | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553445349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525951301 | ||||||||
| FaxNumber: | 6122944903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01057766 | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 64106941 | 05 | KY | MEDICAID | P00764115 | 01 | IN | RAILROAD MEDICARE | OTHER | 063182 | 01 | IN | SIHO | OTHER | P00242551 | 01 | MEDICARE RAILROAD | OTHER | 200523120 | 05 | IN | MEDICAID | 000000371886 | 01 | IN | ANTHEM BCBS | OTHER | P00632696 | 01 | IN | RAILROAD MEDICARE | OTHER |