Basic Information
| Provider Information | |||||||||
| NPI: | 1306044003 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODACH | ||||||||
| FirstName: | KIRK | ||||||||
| MiddleName: | JON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | 5746471825 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 N MICHIGAN ST FL 1 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746473050 | ||||||||
| FaxNumber: | 5746471094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01065817A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | M400050759 | 01 | IN | MEDICARE PTAN | OTHER | P01050896 | 01 | IN | RR MEDICARE | OTHER | 200986910 | 05 | IN | MEDICAID | 000000720320 | 01 | IN | BCBS MEMORIAL HOSPITALIST GROUP | OTHER |