=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699906594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ODE MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2009
-----------------------------------------------------
Last Update Date | 07/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6323 GEORGIA AVE NW SUITE 200
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20011-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-291-1148
-----------------------------------------------------
Fax | 202-291-1205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14725 JAYSTONE DR
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20905-7410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-989-0651
-----------------------------------------------------
Fax | 301-384-1083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMIMISTRATIVE DIRECTOR
-----------------------------------------------------
Name | DIANE M COTTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-873-2529
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | MD16434
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------