1558734517 NPI number — LISA MARIE O'BRIEN PT, DPT, CERT. DN

Table of content: LISA MARIE O'BRIEN PT, DPT, CERT. DN (NPI 1558734517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558734517 NPI number — LISA MARIE O'BRIEN PT, DPT, CERT. DN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'BRIEN
Provider First Name:
LISA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, CERT. DN
Provider Gender Code:
F

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:
1558734517
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2397
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWLEYS ISLAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29585-2397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-235-0200
Provider Business Mailing Address Fax Number:
843-235-0242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4731 HIGHWAY 17
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRELLS INLET
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29576-5090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-314-3224
Provider Business Practice Location Address Fax Number:
843-314-3596
Provider Enumeration Date:
11/12/2015

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: 225100000X , with the licence number:  7923 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q52715C630 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: Q52715E293 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: Q527159403 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: Q52715A382 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: Q52715F404 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: Q527157906 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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