1720046360 NPI number — CRAIG N BODE PT

Table of content: CRAIG N BODE PT (NPI 1720046360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720046360 NPI number — CRAIG N BODE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BODE
Provider First Name:
CRAIG
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1720046360
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 43RD AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOLINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61265-8401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-743-2070
Provider Business Mailing Address Fax Number:
309-743-2073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3605 UNIVERSITY DR STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUSCATINE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52761-9607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-263-2639
Provider Business Practice Location Address Fax Number:
563-263-2691
Provider Enumeration Date:
05/03/2006

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: 225100000X , with the licence number:  02209 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 070-010146 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 070-010146 . This is a "ILLINOIS PT LICENSE NO." identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 02209 . This is a "IOWA PT LICENSE NO." identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".