=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588215362
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURPLE DOGFISH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2019
-----------------------------------------------------
Last Update Date | 09/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6150 EDGELAKE DR
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34240-8803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-954-3698
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 18186
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34276-1186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DO
-----------------------------------------------------
Name | DR. MELISSA MARIE ODERMANN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 541-954-3698
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------