MEDICARE: PATRICIA O'DIERNO

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	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	84545	SC

General Provider Information

NPI Number	:	1447782727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA O'DIERNO

Provider Business Mailing Address
First Line	:	PO BOX 603898
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-3898
Country	:	US
Telephone Number	:	843-792-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	834 W MEETING ST STE C
Second Line	:
City	:	LANCASTER
State	:	SC
Zip	:	29720-6220
Country	:	US
Telephone Number	:	803-285-2700
Fax Number	:

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

Provider Enumeration Date	:	03/28/2017
Last Update Date	:	10/23/2020

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