Dallis Mark Bowditch, M.D.
Individual provider Active NPI Family Medicine Physician · Logansport, IN
NPI 1790788255 · NPPES record last updated Dec 1, 2015
Key facts
- NPI
- 1790788255
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 01032465A (IN)
- Practice address
- 1201 Michigan Ave
Suite 140
Logansport, IN 46947-1580 - Phone
- (574) 753-1462
- Fax
- (574) 753-1465
- NPI assigned
- May 27, 2005
- Sex
- Male
- Sole proprietor
- No
Owned or controlled facilities with NPI records 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| Millers Merry Manor |
Skilled nursing facility | Operational/Managerial Control Adp of the SNF |
Jan 1, 2025 Jun 6, 2025 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20230203002127 | IN | Order and Referring Only - Family Practice |
7012901010 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 01032465A | IN | Yes |
Addresses
Primary practice location
1201 Michigan Ave
Suite 140
Logansport, IN 46947-1580
Mailing address
1201 Michigan Ave
Suite 140
Logansport, IN 46947-1580
Phone (574) 753-1462
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 4216390 | Other | IN | AETNA ID |
| 100070810 | Medicaid | IN | |
| 000000546802 | Other | ANTHEM BLUE CROSS | |
| 6148784003 | Other | IN | CIGNA ID |
| 080096741 | Other | MEDICARE RAILROAD | |
| 112810C | Other | OLD MEDICARE ID # |
Other providers in Logansport, IN
- Ryan Joe Bice
- Mary Elizabeth Blackburn
- Amanda L Bloom
- Michael Dean Bontrager
- Angela Bostic
- Angela Gail Bowen
- Marsha Kay Boyd
- Kristena Brand
- Emily Brooke Brandstatter
- Denise Marie Brehmer
All providers in Logansport, IN · Family Medicine Physician in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 1, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.