Provider Demographics
NPI:1265584668
Name:ODEA MEDICAL GROUP LLC
Entity type:Organization
Organization Name:ODEA MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:KLEEMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:410-296-1464
Mailing Address - Street 1:7505 OSLER DR
Mailing Address - Street 2:SUITE 308
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204
Mailing Address - Country:US
Mailing Address - Phone:410-296-1464
Mailing Address - Fax:410-296-1480
Practice Address - Street 1:7505 OSLER DR
Practice Address - Street 2:SUITE 308
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204
Practice Address - Country:US
Practice Address - Phone:410-296-1464
Practice Address - Fax:410-296-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H949Medicare ID - Type Unspecified