Basic Information
| Provider Information | |||||||||
| NPI: | 1770570400 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'BRYAN | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707449600 | ||||||||
| FaxNumber: | 2707440834 | ||||||||
| Practice Location | |||||||||
| Address1: | 5120 VILLAGE SQUARE DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420019060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704420240 | ||||||||
| FaxNumber: | 2704429599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 04/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 36713 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 01044033A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 36713 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64880495 | 05 | KY | MEDICAID |