Basic Information
| Provider Information | |||||||||
| NPI: | 1518981612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ODELL | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 807 | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600090807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474379889 | ||||||||
| FaxNumber: | 8479441250 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 BIESTERFIELD RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600077324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474379889 | ||||||||
| FaxNumber: | 8474374149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 36112610 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00376430 | 01 | IL | MEDICARE RAILROAD | OTHER | 036112610 | 05 | IL | MEDICAID | 2570089 | 05 | OH | MEDICAID | 36112610 | 01 | IL | STATE LICENSE | OTHER | 212020 | 01 | IL | MEDICARE ID-TYPE UNSPECIF | OTHER |