Provider Demographics
NPI:1245262401
Name:BODENSTAB, PHILIP CHARLES JR (MD)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:CHARLES
Last Name:BODENSTAB
Suffix:JR
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 1:341 N STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148
Mailing Address - Country:US
Mailing Address - Phone:630-611-8029
Mailing Address - Fax:630-691-1216
Practice Address - Street 1:1044 N FRANCISCO AVENUE
Practice Address - Street 2:NORWEGIAN AMERICAN HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:773-278-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21779207L00000X
FLME63662207L00000X
WAMD00015200207L00000X
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C39124Medicare UPIN
167173Medicare ID - Type UnspecifiedHCFA