Provider Demographics
NPI:1144224957
Name:ODEM, CARROLL G (MD)
Entity Type:Individual
Prefix:DR
First Name:CARROLL
Middle Name:G
Last Name:ODEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8309 GRINDER CREEK PL
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2745
Mailing Address - Country:US
Mailing Address - Phone:423-400-9910
Mailing Address - Fax:423-332-5195
Practice Address - Street 1:6380 BELLS FERRY RD STE 107
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-5435
Practice Address - Country:US
Practice Address - Phone:404-989-7384
Practice Address - Fax:855-604-0965
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA51171207R00000X
TNMD24920174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3882406Medicaid
TN3882406Medicaid