Provider Demographics
NPI:1538607726
Name:BODMER FAMILY FOOTCARE PC
Entity type:Organization
Organization Name:BODMER FAMILY FOOTCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-213-4200
Mailing Address - Street 1:29 N MARKET ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-1924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 N MARKET ST
Practice Address - Street 2:SUITE B
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-1924
Practice Address - Country:US
Practice Address - Phone:570-213-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-004288-L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA561096Medicare PIN