Basic Information
| Provider Information | |||||||||
| NPI: | 1881637999 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODNER | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4525 N RAVENSWOOD AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606405201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128578794 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4300 ALTON RD | ||||||||
| Address2: | MRI BUILDING, 2ND FLOOR | ||||||||
| City: | MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056742194 | ||||||||
| FaxNumber: | 3055325241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 11/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | 036.143570 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084P0800X | ME69782 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | ME69782 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084P0800X | 036.143570 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 377478300 | 05 | FL | MEDICAID |