Basic Information
| Provider Information | |||||||||
| NPI: | 1063527208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODNER | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | JEFFREY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2111 MIDLANDS CT | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601783125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157580000 | ||||||||
| FaxNumber: | 8157567130 | ||||||||
| Practice Location | |||||||||
| Address1: | 2111 MIDLANDS CT | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601783125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157580000 | ||||||||
| FaxNumber: | 8157567130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036-104076 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01915167 | 01 | IL | BLUE CROSS/BLUE SHIELD | OTHER | 0359580001 | 01 | IL | DMERC | OTHER | 200040517 | 01 | IL | RAILROAD MEDICARE | OTHER | 036104076 | 05 | IL | MEDICAID | 066360 | 01 | IL | HEALTH ALLIANCE | OTHER |