NPIMap

Individual provider Active NPI

Shelly B Odom Jr., MD

  • Family Medicine Physician
  • Morehead City, NC
National Provider Identifier
1245598929
Registry record updated Dec 11, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
2015-01839 Issued in NC
Practice address
505 N 35TH St
Morehead City, NC 28557-3120
Phone
(252) 726-8414
Fax
(252) 726-9172
NPI assigned
May 1, 2012
Last updated
Dec 11, 2016By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 11, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 2015-01839 NC Primary

Addresses

Primary practice location

505 N 35TH St
Morehead City, NC 28557-3120

Mailing address

505 N 35TH St
Morehead City, NC 28557-3120
Phone (252) 726-8414

Other identifiers 4

IdentifierTypeStateIssuer
0962807OtherNCCIGNA
P01578817OtherNCRAILROAD MEDICARE
193FXOtherNDBCBS OF NC
4187580OtherNCAETNA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20151002001721 NC Practitioner - Family Practice 3870736689 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of South Florida College of Medicine, 2012
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Crystal Coast Family PracticeGroup PAC ID 4486620887, 12 clinicians

Practice addresses (Care Compare)

505 N 35TH St
Morehead City, NC 28557-3120
Phone (252) 726-8414

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions11
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
2015-01839NCMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Crystal Coast Family Practice Family Medicine CurrentSince Aug 28, 2015 Accepting new patients

Locations

540 Cedar Point Blvd
Cedar Point, NC 28584
Phone (252) 393-2532

505 N 35th St
Morehead City, NC 28557
Phone (252) 247-1209

Interoperability endpoints

  • Direct secure messaging: shellyodom@ccfp.allscriptsdirect.net

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1335830400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1481414400000",
    "number": "1245598929",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "505 N 35TH ST",
            "city": "MOREHEAD CITY",
            "state": "NC",
            "postal_code": "285573120",
            "telephone_number": "252-726-8414",
            "fax_number": "252-726-9172"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "505 N 35TH ST",
            "city": "MOREHEAD CITY",
            "state": "NC",
            "postal_code": "285573120",
            "telephone_number": "252-726-8414",
            "fax_number": "252-726-9172"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ODOM",
        "first_name": "SHELLY",
        "middle_name": "B",
        "name_prefix": "Dr.",
        "name_suffix": "Jr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-05-01",
        "last_updated": "2016-12-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NC",
            "license": "2015-01839",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CIGNA",
            "identifier": "0962807",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "P01578817",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF NC",
            "identifier": "193FX",
            "state": "ND"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "4187580",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Morehead City, NC

Sources for this page

Verify at the official NPI Registry.