Healthcare Provider Details

I. General information

NPI: 1134234990
Provider Name (Legal Business Name): SCOTT D. BODEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 EXECUTIVE PARK SOUTH NE SUITE 3000
ATLANTA GA
30329-2208
US

IV. Provider business mailing address

59 EXECUTIVE PARK SOUTH NE SUITE 3000
ATLANTA GA
30329-2208
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-7143
  • Fax: 404-778-7117
Mailing address:
  • Phone: 404-778-7143
  • Fax: 404-778-7117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number035566
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: