Healthcare Provider Details

I. General information

NPI: 1083028849
Provider Name (Legal Business Name): SUSAN ODOM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E WENDOVER AVE
GREENSBORO NC
27405-6713
US

IV. Provider business mailing address

4007 HAZEL LN
GREENSBORO NC
27408-3191
US

V. Phone/Fax

Practice location:
  • Phone: 336-641-4135
  • Fax:
Mailing address:
  • Phone: 336-299-2196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number248328
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: