Provider Demographics
NPI:1699944264
Name:BOVELL, PHILIP BENJAMIN (MD)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:BENJAMIN
Last Name:BOVELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11701 LIVINGSTON ROAD
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 ROAD
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:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0020121207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD354161400Medicaid
DC02663880Medicaid
B94896Medicare UPIN
004017P57Medicare PIN