MEDICARE: MARTHA M O'DANOVICH PSYD

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	103T00000X	Psychologist	35000126A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912992819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA M O'DANOVICH PSYD

Provider Business Mailing Address
First Line	:	8300 BROADWAY
Second Line	:	F1
City	:	MERRILLVILLE
State	:	IN
Zip	:	46410-8602
Country	:	US
Telephone Number	:	219-736-1000
Fax Number	:	219-736-9699

Provider Business Practice Location Address
First Line	:	8300 BROADWAY
Second Line	:	F1
City	:	MERRILLVILLE
State	:	IN
Zip	:	46410-8602
Country	:	US
Telephone Number	:	219-736-1000
Fax Number	:	219-736-9699

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

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	08/28/2014

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