Basic Information
| Provider Information | |||||||||
| NPI: | 1588028963 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODE | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 E. THIRD STREET | ||||||||
| Address2: | BOX 159-PAYER RELATIONS | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237785179 | ||||||||
| FaxNumber: | 4237782108 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237785179 | ||||||||
| FaxNumber: | 4237782108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 07/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO3756 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | DO3756 | TN | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | DO3756 | 01 | TN | MEDICAL LICENSE | OTHER |