Healthcare Provider Details

I. General information

NPI: 1477831188
Provider Name (Legal Business Name): MICHAEL FRIEDRICH JOHANNES BODE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 N BROAD ST
PHILADELPHIA PA
19140-4105
US

IV. Provider business mailing address

3509 N BROAD ST
PHILADELPHIA PA
19140-4105
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-8484
  • Fax: 215-707-3946
Mailing address:
  • Phone: 215-707-8484
  • Fax: 215-707-3946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036157978
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number274222
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036157978
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD477544
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: