Provider Demographics
NPI:1679672497
Name:TERRY W ODOM PEDIATRICS
Entity Type:Organization
Organization Name:TERRY W ODOM PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D. -OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-256-9391
Mailing Address - Street 1:702 EARL FRYE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-9403
Mailing Address - Country:US
Mailing Address - Phone:662-256-9391
Mailing Address - Fax:662-256-4307
Practice Address - Street 1:702 EARL FRYE BLVD
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-9403
Practice Address - Country:US
Practice Address - Phone:662-256-9391
Practice Address - Fax:662-256-4307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06136862Medicaid