Provider Demographics
NPI:1588028963
Name:BODE, RYAN (DO)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BODE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 E. THIRD STREET
Mailing Address - Street 2:BOX 159-PAYER RELATIONS
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403
Mailing Address - Country:US
Mailing Address - Phone:423-778-5179
Mailing Address - Fax:423-778-2108
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-5179
Practice Address - Fax:423-778-2108
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO3756207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDO3756OtherMEDICAL LICENSE