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General NPI Number Information
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NPI Number | 1033340013
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Entity Type | Organization
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Legal Business Name | KIP L BODI PHYSICIAN FACS PLLC
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Dates
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Enumeration Date | 08/07/2009
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Last Update Date | 08/07/2009
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Provider Practice Location Address
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Address Line | 775 PARK AVE SUITE 262
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City | HUNTINGTON
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State | NY
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Zip | 11743-3976
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Country | US
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Telephone | 631-271-1608
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Fax | 631-271-1968
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Provider Business Mailing Address
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Address Line | 775 PARK AVE SUITE 262
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City | HUNTINGTON
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State | NY
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Zip | 11743-3976
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Country | US
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Telephone | 631-271-1608
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Fax | 631-271-1968
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KIP L BODI
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Credential | M.D.,F.A.C.S.
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Telephone | 631-271-1608
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 144782
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License Number State | NY
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