1174733125 NPI number — JASON B O'DELL MD

Table of content: JASON B O'DELL MD (NPI 1174733125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174733125 NPI number — JASON B O'DELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'DELL
Provider First Name:
JASON
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174733125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3239
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29502-3239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-777-7092
Provider Business Mailing Address Fax Number:
843-777-7102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 E CHEVES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29506-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-777-7900
Provider Business Practice Location Address Fax Number:
843-777-7102
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  27197 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: ME103720 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0004X , with the licence number: 27197 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00052500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9234356 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 21464 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 329791 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 9250826 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 23163 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 271976 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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