Provider Demographics
NPI:1104818582
Name:PHILIP B BOVELL, MDPA
Entity type:Organization
Organization Name:PHILIP B BOVELL, MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:BOVELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-292-0757
Mailing Address - Street 1:11701 LIVINGSTON RD
Mailing Address - Street 2:STE 204
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5104
Mailing Address - Country:US
Mailing Address - Phone:301-292-0757
Mailing Address - Fax:
Practice Address - Street 1:11701 LIVINGSTON RD
Practice Address - Street 2:STE 204
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5104
Practice Address - Country:US
Practice Address - Phone:301-292-0757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0020121207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC02663880Medicaid
430357Medicare ID - Type Unspecified
DC02663880Medicaid