Healthcare Provider Details

I. General information

NPI: 1528353372
Provider Name (Legal Business Name): ODETTE ADEAN ANDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 02/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MEDICAL PARK STE 141 GENERAL PSYCHIATRY
COLUMBIA SC
29203
US

IV. Provider business mailing address

15 MEDICAL PARK STE 141 GENERAL PSYCHIATRY
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-1433
  • Fax: 803-434-4351
Mailing address:
  • Phone: 803-434-1433
  • Fax: 803-434-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLL33577
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number307350
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: