Healthcare Provider Details

I. General information

NPI: 1639705767
Provider Name (Legal Business Name): BENJAMIN ODOM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 BLUE LAKE DR STE 110
VESTAVIA AL
35243-2372
US

IV. Provider business mailing address

406 N ELM ST
MOUNT PLEASANT TN
38474-1217
US

V. Phone/Fax

Practice location:
  • Phone: 205-977-1949
  • Fax: 205-977-1933
Mailing address:
  • Phone: 205-441-2996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-142308
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: