Provider Demographics
NPI:1063527208
Name:BODNER, RUSSELL JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JEFFREY
Last Name:BODNER
Suffix:
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 1:2111 MIDLANDS CT
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3125
Mailing Address - Country:US
Mailing Address - Phone:815-758-0000
Mailing Address - Fax:815-756-7130
Practice Address - Street 1:2111 MIDLANDS CT
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3125
Practice Address - Country:US
Practice Address - Phone:815-758-0000
Practice Address - Fax:815-756-7130
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104076207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01915167OtherBLUE CROSS/BLUE SHIELD
IL0359580001OtherDMERC
IL200040517OtherRAILROAD MEDICARE
IL036104076Medicaid
IL066360OtherHEALTH ALLIANCE
IL01915167OtherBLUE CROSS/BLUE SHIELD
IL0359580001OtherDMERC