Provider Demographics
NPI:1932320256
Name:ODYSSEY MEDICAL GROUP
Entity Type:Organization
Organization Name:ODYSSEY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-821-7658
Mailing Address - Street 1:4832 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6917
Mailing Address - Country:US
Mailing Address - Phone:310-821-7658
Mailing Address - Fax:310-821-1708
Practice Address - Street 1:4832 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6917
Practice Address - Country:US
Practice Address - Phone:310-821-7658
Practice Address - Fax:310-821-1708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4238174400000X
CAG79180174400000X
CAC35069174400000X
CAA96388174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicare UPIN
CAW17854Medicare ID - Type Unspecified