Provider Demographics
NPI:1528143856
Name:BODLEY, MICHAEL T (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:BODLEY
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1108 W STATE ST STE 3
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-9711
Practice Address - Country:US
Practice Address - Phone:269-945-0922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030311207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16150181Medicare ID - Type Unspecified
MI0M74460337Medicare PIN
MIB43882Medicare UPIN