1841221348 NPI number — MARK E OBRIEN MD

Table of content: MARK E OBRIEN MD (NPI 1841221348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841221348 NPI number — MARK E OBRIEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OBRIEN
Provider First Name:
MARK
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841221348
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 INDUSTRIAL PARK DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-427-7937
Provider Business Mailing Address Fax Number:
269-427-5180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 M 139
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON HARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49022-3881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-927-5400
Provider Business Practice Location Address Fax Number:
269-927-5493
Provider Enumeration Date:
07/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301080677 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 4301080677 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4605349 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".