MEDICARE: DR. CARROLL G ODEM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	51171	GA
2	174400000X	Specialist	MD24920	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144224957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARROLL G ODEM MD

Provider Business Mailing Address
First Line	:	8309 GRINDER CREEK PL
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-2745
Country	:	US
Telephone Number	:	423-400-9910
Fax Number	:	423-332-5195

Provider Business Practice Location Address
First Line	:	6380 BELLS FERRY RD STE 107
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30102-5435
Country	:	US
Telephone Number	:	404-989-7384
Fax Number	:	855-604-0965

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	03/12/2021

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