Healthcare Provider Details

I. General information

NPI: 1932580917
Provider Name (Legal Business Name): EMILY BODEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY DANIELLE REINBOLD MD

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 10TH AVE W
MOBRIDGE SD
57601-1146
US

IV. Provider business mailing address

1309 10TH AVE W
MOBRIDGE SD
57601-1146
US

V. Phone/Fax

Practice location:
  • Phone: 605-845-3692
  • Fax: 605-845-8239
Mailing address:
  • Phone: 605-845-3692
  • Fax: 605-845-8239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11018400A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11018400A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11168
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: