=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922062157
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY O'DONNELL D.O., MBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2006
-----------------------------------------------------
Last Update Date | 12/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 POND PARK RD STE 303
-----------------------------------------------------
City | HINGHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02043-4354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-624-2525
-----------------------------------------------------
Fax | 781-741-6297
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 62 13TH ST
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02129-2056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-952-5299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 25MB07680200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | OS013626
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | DO00614
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | DO00614
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | OS11404
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 234536
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------