Healthcare Provider Details

I. General information

NPI: 1538059779
Provider Name (Legal Business Name): ODAM MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 PENN ST
FOLEY MN
56329-8700
US

IV. Provider business mailing address

700 PENN ST
FOLEY MN
56329-8700
US

V. Phone/Fax

Practice location:
  • Phone: 320-774-3800
  • Fax: 320-774-3360
Mailing address:
  • Phone: 320-774-3800
  • Fax: 612-871-2163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT LARBI-ODAM
Title or Position: CEO
Credential: MD
Phone: 612-871-2312