Healthcare Provider Details

I. General information

NPI: 1467413989
Provider Name (Legal Business Name): RUTH M ODACHOWSKI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RUTH M WILSON PA

II. Dates (important events)

Enumeration Date: 04/01/2006
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 WASHINGTON RD SUITE 102
WESTMINSTER MD
21157-6664
US

IV. Provider business mailing address

535 OLD WESTMINSTER PIKE SUITE 102
WESTMINSTER MD
21157-6267
US

V. Phone/Fax

Practice location:
  • Phone: 410-871-0088
  • Fax: 410-871-0083
Mailing address:
  • Phone: 410-871-6864
  • Fax: 410-871-6226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC003248
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: