Provider Demographics
NPI:1578934683
Name:ODAM MEDICAL GROUP
Entity Type:Organization
Organization Name:ODAM MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LARBI-ODAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-992-9305
Mailing Address - Street 1:6014 LAKELAND AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-2984
Mailing Address - Country:US
Mailing Address - Phone:612-871-2312
Mailing Address - Fax:612-871-2163
Practice Address - Street 1:6014 LAKELAND AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-2984
Practice Address - Country:US
Practice Address - Phone:612-871-2312
Practice Address - Fax:612-871-2163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care