1770534372 NPI number — GEOFFREY R BODEAU M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770534372 NPI number — GEOFFREY R BODEAU M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BODEAU

Provider First Name:

GEOFFREY

Provider Middle Name:

R

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1770534372

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/19/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

6608 KENNEY PL

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

EDINA

Provider Business Mailing Address State Name:

MN

Provider Business Mailing Address Postal Code:

55439-1427

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

952-947-9445

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

6608 KENNEY PL

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

EDINA

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

55439-1427

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

952-947-9445

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

05/16/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2085N0904X , with the licence number:  29842 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 4T045BO . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: HP12925 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 108789 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 0533448 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 300046433 . This is a "RAILROAD MEDICARE WI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
• Identifier: 22825 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 32385300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 47Q34BO . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: P00126385 . This is a "RAILROAD MEDCIARE MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 232903 . This is a "MIDLANDS CHOICE INC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 794265600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 1006999 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 9253416 . This is a "DAKOTA CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".