1417577024 NPI number — MATTHEW CHRISTOPHER O'BRIEN DO

Table of content: MATTHEW CHRISTOPHER O'BRIEN DO (NPI 1417577024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417577024 NPI number — MATTHEW CHRISTOPHER O'BRIEN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'BRIEN
Provider First Name:
MATTHEW
Provider Middle Name:
CHRISTOPHER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1417577024
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
534 SAMANTHA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60502-9045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-639-6360
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 SAINT ANTOINE ST STE 9C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201-2153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-577-5009
Provider Business Practice Location Address Fax Number:
313-577-5310
Provider Enumeration Date:
04/23/2020

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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