Basic Information
| Provider Information | |||||||||
| NPI: | 1639823412 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEVIN OBI NP IN PSYCHIATRY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1131 ELKER RD | ||||||||
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| City: | UNION | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070835006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733425593 | ||||||||
| FaxNumber: | 6464908780 | ||||||||
| Practice Location | |||||||||
| Address1: | 4377 BRONX BLVD | ||||||||
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| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104661397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3479127566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2022 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | OBI | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER IN PSYCHIATRY | ||||||||
| AuthorizedOfficialTelephone: | 9733425593 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSN | ||||||||
| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 5427909 | 05 | NY | MEDICAID |