Provider Demographics
NPI:1376607713
Name:SOUTH ISLAND PODIATRY SPECIALISTS,PC
Entity Type:Organization
Organization Name:SOUTH ISLAND PODIATRY SPECIALISTS,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BODAMER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-447-0800
Mailing Address - Street 1:1641 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3635
Mailing Address - Country:US
Mailing Address - Phone:631-447-0800
Mailing Address - Fax:631-447-0801
Practice Address - Street 1:1641 ROUTE 112
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3635
Practice Address - Country:US
Practice Address - Phone:631-447-0800
Practice Address - Fax:631-447-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0-3889213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5866630001Medicare NSC
NYP0W821Medicare PIN