MEDICARE: T. GERALD O'DANIEL M.D., PLLC

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	2086S0122X	Plastic and Reconstructive Surgery Physician	24070	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	KY1118	OTHER	KY	HEALTHNET
2	1058697	OTHER	KY	PASSPORT PIN
3	000000219660	OTHER	KY	ANTHEM PIN
4	002	OTHER	KY	CIGNA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	667357	OTHER	KY	HEALTHLINK
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	KY0057799	OTHER	KY	TRICARE

General Provider Information

NPI Number	:	1457498107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	T. GERALD O'DANIEL M.D., PLLC

Provider Business Mailing Address
First Line	:	222 S 1ST ST
Second Line	:	SUITE 100
City	:	LOUISVILLE
State	:	KY
Zip	:	40202-1350
Country	:	US
Telephone Number	:	502-584-1109
Fax Number	:	502-589-6882

Provider Business Practice Location Address
First Line	:	222 S 1ST ST
Second Line	:	SUITE 100
City	:	LOUISVILLE
State	:	KY
Zip	:	40202-1350
Country	:	US
Telephone Number	:	502-584-1109
Fax Number	:	502-589-6882

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	DR. T. GERALD O'DANIEL
Credential	:	M.D., PLLC
Telephone Number	:	502-584-1109

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	10/28/2010

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