Healthcare Provider Details

I. General information

NPI: 1578934683
Provider Name (Legal Business Name): ODAM MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6014 LAKELAND AVE N
CRYSTAL MN
55428-2984
US

IV. Provider business mailing address

6014 LAKELAND AVE N
CRYSTAL MN
55428-2984
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-2312
  • Fax: 612-871-2163
Mailing address:
  • Phone: 612-871-2312
  • Fax: 612-871-2163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT LARBI-ODAM
Title or Position: CEO/MEDICAL DIRECTOR
Credential: M.D.
Phone: 952-992-9305