Basic Information
| Provider Information | |||||||||
| NPI: | 1780648303 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODEMANN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | LOUIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21850 | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719031850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016232781 | ||||||||
| FaxNumber: | 5016231774 | ||||||||
| Practice Location | |||||||||
| Address1: | 1662 HIGDON FERRY RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719136912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016232781 | ||||||||
| FaxNumber: | 5016231774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 04/04/2019 | ||||||||
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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 | 207R00000X | N6024 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102441001 | 05 | AR | MEDICAID |