=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306044003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRK JON BODACH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2007
-----------------------------------------------------
Last Update Date | 03/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 N MICHIGAN ST FL 1
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-647-3050
-----------------------------------------------------
Fax | 574-647-1094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 N NILES AVE
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46617-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-647-1610
-----------------------------------------------------
Fax | 574-647-1825
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01065817A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------