Basic Information
Provider Information | |||||||||
NPI: | 1558977942 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ODYSSEY HEALTHCARE OPERATING A LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4060 | ||||||||
Address2: |   | ||||||||
City: | MOORESVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 281174060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7046640416 | ||||||||
FaxNumber: | 7046641306 | ||||||||
Practice Location | |||||||||
Address1: | 4120 DUBLIN BLVD STE 105 | ||||||||
Address2: |   | ||||||||
City: | DUBLIN | ||||||||
State: | CA | ||||||||
PostalCode: | 945687759 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9257370203 | ||||||||
FaxNumber: | 9257370245 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2020 | ||||||||
LastUpdateDate: | 09/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCGEE | ||||||||
AuthorizedOfficialFirstName: | PATIENCE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF REGULATORY & LIC SERVICES | ||||||||
AuthorizedOfficialTelephone: | 7046620416 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X |   |   | N |   | Agencies | Hospice Care, Community Based |   | 207RH0002X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
No ID Information.