Provider Demographics
NPI:1033425962
Name:ODELL STILL DO LLC
Entity Type:Organization
Organization Name:ODELL STILL DO LLC
Other - Org Name:SOUTHEAST REGIONAL PRIMARY CARE CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:OSTEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-538-5314
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-537-4986
Mailing Address - Fax:
Practice Address - Street 1:28 W RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:GA
Practice Address - Zip Code:30411-3513
Practice Address - Country:US
Practice Address - Phone:912-568-1407
Practice Address - Fax:912-568-1579
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST REGIONAL PRIMARY CARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-30
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty