Basic Information
| Provider Information | |||||||||
| NPI: | 1184810491 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RICHARD O'BRIEN, MD, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 EAST 9TH AVE #550 | ||||||||
| Address2: | RICHARD O'BRIEN, MD, LLC | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033298998 | ||||||||
| FaxNumber: | 3033299020 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 EAST 9TH AVE #550 | ||||||||
| Address2: | RICHARD O'BRIEN, MD, LLC | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033298998 | ||||||||
| FaxNumber: | 3033299020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2007 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | RADICH | ||||||||
| AuthorizedOfficialFirstName: | TAMARA | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3034230758 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 24590 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 24590 | 01 | CO | COLORADO LIC | OTHER | 01245901 | 05 | CO | MEDICAID |