Provider Demographics
NPI:1154354835
Name:SOONER INTERNAL MEDICINE, LLC
Entity type:Organization
Organization Name:SOONER INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-781-0224
Mailing Address - Street 1:1002 MC INTOSH CIR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3642
Mailing Address - Country:US
Mailing Address - Phone:417-781-0224
Mailing Address - Fax:417-781-0692
Practice Address - Street 1:1002 MC INTOSH CIR
Practice Address - Street 2:SUITE 1
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3642
Practice Address - Country:US
Practice Address - Phone:417-781-0224
Practice Address - Fax:417-781-0692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001017184207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH44369Medicare UPIN