Provider Demographics
NPI:1356518682
Name:MARK G BODDY
Entity type:Organization
Organization Name:MARK G BODDY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-738-0404
Mailing Address - Street 1:840 PINE ST
Mailing Address - Street 2:SUITE 990
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2100
Mailing Address - Country:US
Mailing Address - Phone:478-738-0404
Mailing Address - Fax:478-738-0805
Practice Address - Street 1:840 PINE ST
Practice Address - Street 2:SUITE 990
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2100
Practice Address - Country:US
Practice Address - Phone:478-738-0404
Practice Address - Fax:478-738-0805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032519174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3233OtherGROUP