Provider Demographics
NPI:1033340013
Name:KIP L BODI PHYSICIAN FACS PLLC
Entity Type:Organization
Organization Name:KIP L BODI PHYSICIAN FACS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:BODI
Authorized Official - Suffix:
Authorized Official - Credentials:MD,FACS
Authorized Official - Phone:631-271-1608
Mailing Address - Street 1:775 PARK AVE
Mailing Address - Street 2:SUITE 262
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3976
Mailing Address - Country:US
Mailing Address - Phone:631-271-1608
Mailing Address - Fax:631-271-1968
Practice Address - Street 1:775 PARK AVE
Practice Address - Street 2:SUITE 262
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3976
Practice Address - Country:US
Practice Address - Phone:631-271-1608
Practice Address - Fax:631-271-1968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-07
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144782208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB14386Medicare UPIN