Basic Information
| Provider Information | |||||||||
| NPI: | 1275589442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OBRIEN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 99 EAST STATE STREET | ||||||||
| Address2: | PO BOX 1250 | ||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120780100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187735690 | ||||||||
| FaxNumber: | 5187735620 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 EAST STATE STREET | ||||||||
| Address2: | |||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120780100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187735690 | ||||||||
| FaxNumber: | 5187735620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 08/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 220363 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02221341 | 05 | NY | MEDICAID | 3012085 | 01 | NY | MVP HEALTH PLAN | OTHER | 000921689002 | 01 | NY | BSH NE NY | OTHER | 100766990 | 01 | NY | CDPHP | OTHER |