Healthcare Provider Details

I. General information

NPI: 1689659179
Provider Name (Legal Business Name): JOSEPH F BODIN III PA-AA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

PO BOX 551420
FT LAUDERDALE FL
33355-1420
US

V. Phone/Fax

Practice location:
  • Phone: 866-507-5244
  • Fax: 855-851-4405
Mailing address:
  • Phone: 800-243-3839
  • Fax: 855-851-4405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number007524
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberAA-828
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: