MEDICARE: MR. PATRICK CLARK O'DONNELL III ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL5215	FL

General Provider Information

NPI Number	:	1124487871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PATRICK CLARK O'DONNELL III ATC

Provider Business Mailing Address
First Line	:	1244 ALAPAHA LN
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-5229
Country	:	US
Telephone Number	:	219-588-0833
Fax Number	:

Provider Business Practice Location Address
First Line	:	3009 98TH ST
Second Line	:
City	:	HIGHLAND
State	:	IN
Zip	:	46322-3343
Country	:	US
Telephone Number	:	219-588-0833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2016
Last Update Date	:	01/28/2019

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