Healthcare Provider Details

I. General information

NPI: 1093197980
Provider Name (Legal Business Name): MICHAEL STEPHEN ODOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12016 N RADIO STATION RD
SENECA SC
29678-1143
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-882-6141
  • Fax: 864-882-6680
Mailing address:
  • Phone: 864-695-6697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38156
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: