Basic Information
| Provider Information | |||||||||
| NPI: | 1891797205 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODI | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 E CHESTER PIKE | ||||||||
| Address2: | |||||||||
| City: | RIDLEY PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190782212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105956586 | ||||||||
| FaxNumber: | 6105956787 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 E CHESTER PIKE | ||||||||
| Address2: | |||||||||
| City: | RIDLEY PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190782212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105956586 | ||||||||
| FaxNumber: | 6105956787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 10/22/2012 | ||||||||
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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 | 363AS0400X | C5-0000626 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | MA003157L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.