MEDICARE: WILLIAM ODONNELL

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	103TC0700X	Clinical Psychologist	0521	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04337	OTHER	NC	BCBS
2	04337	OTHER	NC	NC STATE HEALTH PLAN

General Provider Information

NPI Number	:	1699891408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM ODONNELL

Provider Business Mailing Address
First Line	:	PO BOX 458
Second Line	:
City	:	N TOPSAIL BEACH
State	:	NC
Zip	:	28460-0458
Country	:	US
Telephone Number	:	910-328-3334
Fax Number	:

Provider Business Practice Location Address
First Line	:	3612 ISLAND DR
Second Line	:
City	:	N TOPSAIL BEACH
State	:	NC
Zip	:	28460-8204
Country	:	US
Telephone Number	:	910-328-3334
Fax Number	:

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/09/2007

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