Basic Information
| Provider Information | |||||||||
| NPI: | 1689673790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODDIE | ||||||||
| FirstName: | ELLENA | ||||||||
| MiddleName: | LOIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 REMINGTON BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604405114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303127755 | ||||||||
| FaxNumber: | 6308569933 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 REMINGTON BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604405114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303127755 | ||||||||
| FaxNumber: | 6308569933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036116967 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | M15405 | ID | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 00041414 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME146842 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 01057385A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 4301502442 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | TM2020-0627 | NM | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 13001A | WY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 036116967 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.