MEDICARE: DR. KENNETH EDWARD BODEK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	2013-01642	NC
2	207RC0000X	Cardiovascular Disease Physician	MD046703L	PA
3	207UN0901X	Nuclear Cardiology Physician	MD046703L	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	024733E15	OTHER	PA	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871587923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH EDWARD BODEK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 751803
Second Line	:	SUITE 400
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1803
Country	:	US
Telephone Number	:	336-277-2000
Fax Number	:	336-277-2050

Provider Business Practice Location Address
First Line	:	186 KIMEL PARK DR
Second Line	:	SUITE 400
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6946
Country	:	US
Telephone Number	:	336-277-2000
Fax Number	:	336-277-2050

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	11/15/2023

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Directions to “ DR. KENNETH EDWARD BODEK M.D.” Practice Location

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