Provider Demographics
NPI:1306044003
Name:BODACH, KIRK JON (MD)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:JON
Last Name:BODACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-647-1825
Practice Address - Street 1:615 N MICHIGAN ST FL 1
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-3050
Practice Address - Fax:574-647-1094
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065817A207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400050759OtherMEDICARE PTAN
INP01050896OtherRR MEDICARE
IN200986910Medicaid
IN000000720320OtherBCBS MEMORIAL HOSPITALIST GROUP
INP01050896OtherRR MEDICARE
IN000000738250OtherBCBS MED PT MAIN ST
INM400050759Medicare PIN
IN000000738250OtherBCBS MED PT MAIN ST