Basic Information
| Provider Information | |||||||||
| NPI: | 1184726085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ODLE | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6749 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402060749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028997646 | ||||||||
| FaxNumber: | 5028997648 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 KRESGE WAY | ||||||||
| Address2: | EMERGENCY DEPARTMENT BAPTIST HEALTH LOUISVILLE | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028997646 | ||||||||
| FaxNumber: | 5028997648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 03/25/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35847 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200355490 | 05 | IN | MEDICAID | 64042492 | 05 | KY | MEDICAID | 35847 | 01 | KY | KY LICENSE | OTHER | 000000786307 | 01 | KY | ANTHEM BC/BS | OTHER | 50042929 | 01 | KY | PASSPORT | OTHER | BO6816233 | 01 | DEA | OTHER |