Healthcare Provider Details

I. General information

NPI: 1033196084
Provider Name (Legal Business Name): GARY BODNARCHUK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1532 LONE OAK RD SUITE 310
PADUCAH KY
42003-7913
US

IV. Provider business mailing address

PO BOX 636961
CINCINNATI OH
45263-6961
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-0777
  • Fax: 270-443-0999
Mailing address:
  • Phone: 513-981-5130
  • Fax: 513-981-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number28275
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036.075177
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: