Basic Information
| Provider Information | |||||||||
| NPI: | 1205808276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1575 N OLD TRL | ||||||||
| Address2: | |||||||||
| City: | SELINSGROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178708381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703748555 | ||||||||
| FaxNumber: | 5703749933 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 N OLD TRL | ||||||||
| Address2: | |||||||||
| City: | SELINSGROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178708381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703748555 | ||||||||
| FaxNumber: | 5703749933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 12/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | MD024174E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RX0202X | 235282-1 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00949440 | 05 | NY | MEDICAID | CC9269 | 01 | PA | RR MEDICARE GROUP | OTHER | GU039841 | 01 | PA | PA MEDICARE GROUP | OTHER | 0010399860010 | 05 | PA | MEDICAID | P00127810 | 01 | PA | RR MEDICARE PIN | OTHER |