Provider Demographics
NPI:1902392525
Name:ODAM MEDICAL GROUP
Entity Type:Organization
Organization Name:ODAM MEDICAL GROUP
Other - Org Name:ODAM MEDICAL GROUP - ST. CLOUD
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
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:
Authorized Official - Phone:612-871-2312
Mailing Address - Street 1:1000 S BENTON DR UNIT 421
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-1419
Mailing Address - Country:US
Mailing Address - Phone:320-774-3800
Mailing Address - Fax:320-774-3360
Practice Address - Street 1:1000 S BENTON DR UNIT 421
Practice Address - Street 2:
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-1419
Practice Address - Country:US
Practice Address - Phone:320-774-3800
Practice Address - Fax:320-774-3360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-06
Last Update Date:2023-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health