Basic Information
| Provider Information | |||||||||
| NPI: | 1679684211 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOWEN | ||||||||
| FirstName: | MARCHELE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE STE 1223 | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702040 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5005 HONONEGAH RD | ||||||||
| Address2: | |||||||||
| City: | ROSCOE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610738682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156232555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036105223 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036105223 | 05 | IL | MEDICAID |