Provider Demographics
NPI:1639705767
Name:ODOM, BENJAMIN (CRNA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:ODOM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TN
Mailing Address - Zip Code:38474-1217
Mailing Address - Country:US
Mailing Address - Phone:205-441-2996
Mailing Address - Fax:
Practice Address - Street 1:3104 BLUE LAKE DR STE 110
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243-2372
Practice Address - Country:US
Practice Address - Phone:205-977-1949
Practice Address - Fax:205-977-1933
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-142308367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty