=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811160914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | G PATRICK O'DONNELL M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2008
-----------------------------------------------------
Last Update Date | 04/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15510 OLIVE BLVD SUITE 115
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-0710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-537-2702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15510 OLIVE BLVD SUITE 115
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-0710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-537-2702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GLENN PATRICK O'DONNELL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 636-537-2702
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | MDR5B99
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------