Basic Information
| Provider Information | |||||||||
| NPI: | 1598907453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3046 | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193550746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758511505 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5575 KIETZKE LN | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895112290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758511505 | ||||||||
| FaxNumber: | 7758511583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 05/08/2018 | ||||||||
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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 | 207Q00000X | 14263 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1598907453 | 01 | NPI | OTHER | 12396215 | 01 | CAQH | OTHER |