Provider Demographics
NPI:1134213101
Name:BEN J. O'DELL, MD, PSC
Entity type:Organization
Organization Name:BEN J. O'DELL, MD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'DELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-833-0333
Mailing Address - Street 1:700 ST. CHRISTOPHER DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7061
Mailing Address - Country:US
Mailing Address - Phone:606-833-0333
Mailing Address - Fax:606-833-0070
Practice Address - Street 1:700 ST. CHRISTOPHER DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7061
Practice Address - Country:US
Practice Address - Phone:606-833-0333
Practice Address - Fax:606-833-0070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28279207R00000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64282791Medicaid
KY000000049479OtherBLUECROSS
1521401Medicare ID - Type Unspecified
KY64282791Medicaid