Provider Demographics
NPI:1467413989
Name:ODACHOWSKI, RUTH M (PA)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:M
Last Name:ODACHOWSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:M
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:535 OLD WESTMINSTER PIKE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6267
Mailing Address - Country:US
Mailing Address - Phone:410-871-6864
Mailing Address - Fax:410-871-6226
Practice Address - Street 1:844 WASHINGTON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6664
Practice Address - Country:US
Practice Address - Phone:410-871-0088
Practice Address - Fax:410-871-0083
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC003248363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1360646USDMedicare PIN