Basic Information
| Provider Information | |||||||||
| NPI: | 1598178352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODELL | ||||||||
| FirstName: | BRYCEN | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BODELL | ||||||||
| OtherFirstName: | BRYCE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 925 E MCDOWELL RD FL 2 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028393339 | ||||||||
| FaxNumber: | 6028393300 | ||||||||
| Practice Location | |||||||||
| Address1: | 8701 W WATERTOWN PLANK RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149554575 | ||||||||
| FaxNumber: | 4149556409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 67931-20 | WI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208600000X | R74636 | AZ | N | Allopathic & Osteopathic Physicians | Surgery | 390200000X | TL.000865 | CO | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0204X | 67931 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.