Provider Demographics
NPI:1376541938
Name:BODIE, MICHELLE E (PAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:E
Last Name:BODIE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W STRUB RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-5390
Mailing Address - Country:US
Mailing Address - Phone:419-626-6700
Mailing Address - Fax:419-626-6710
Practice Address - Street 1:2500 W STRUB RD
Practice Address - Street 2:SUITE 330
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5390
Practice Address - Country:US
Practice Address - Phone:419-626-6700
Practice Address - Fax:419-626-6710
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000349619OtherANTHEM BLUE CROSS
OHP00195046OtherRR MEDICAR
OH000000349619OtherANTHEM BLUE CROSS
OHBOPA16273Medicare ID - Type Unspecified
OHP00195046OtherRR MEDICAR