=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639271513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DWIGHT O'DELL, M.D., LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2006
-----------------------------------------------------
Last Update Date | 10/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4550 MEMORIAL DR SUITE 200
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62226-5359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-233-5998
-----------------------------------------------------
Fax | 618-233-6001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4550 MEMORIAL DR SUITE 200
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62226-5359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-233-5998
-----------------------------------------------------
Fax | 618-233-6001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DWIGHT WILLIAM O'DELL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 618-233-5998
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------