1184713661 NPI number — DR. BARRY PAUL BODEN MD

Table of content: DR. BARRY PAUL BODEN MD (NPI 1184713661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184713661 NPI number — DR. BARRY PAUL BODEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BODEN
Provider First Name:
BARRY
Provider Middle Name:
PAUL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184713661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 79831
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21279-0831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-251-1433
Provider Business Mailing Address Fax Number:
301-424-5266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14995 SHADY GROVE RD STE 350
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20850-8726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-251-1433
Provider Business Practice Location Address Fax Number:
301-424-5266
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  D0050899 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: D0050899 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 347535 . This is a "MDIPA/OPCHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5405091004 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 093557 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 217566133 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 347535 . This is a "ALLIANCE/MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 54223602 . This is a "CAREFIRST BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 37520008 . This is a "BLUE CROSS OF NATL CAP AR" identifier . This identifiers is of the category "OTHER".




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