Provider Demographics
NPI:1477593143
Name:ODELL, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:ODELL
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:PO BOX 37087
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3087
Mailing Address - Country:US
Mailing Address - Phone:828-687-5616
Mailing Address - Fax:828-650-8076
Practice Address - Street 1:438 E VANN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-7202
Practice Address - Country:US
Practice Address - Phone:423-278-1700
Practice Address - Fax:423-278-1708
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN005807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN31442811Medicaid
TNMD5807OtherSTATE LICENSES
B59204Medicare UPIN
TN31442811Medicaid
TNP00414415Medicare PIN