MEDICARE: DR. GRAEL O'BRIEN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	039887	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	10453102	OTHER	CT	CAQH

General Provider Information

NPI Number	:	1366454621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRAEL O'BRIEN M.D.

Provider Business Mailing Address
First Line	:	131 COVENTRY ST
Second Line	:	BURGDORF CLINIC - 2ND FLOOR ADMINISTRATION
City	:	HARTFORD
State	:	CT
Zip	:	06112-1548
Country	:	US
Telephone Number	:	860-714-3690
Fax Number	:	860-714-8683

Provider Business Practice Location Address
First Line	:	131 COVENTRY ST
Second Line	:	BURGDORF CLINIC - 2ND FLOOR ADMINISTRATION
City	:	HARTFORD
State	:	CT
Zip	:	06112-1548
Country	:	US
Telephone Number	:	860-714-3690
Fax Number	:	860-714-8683

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	10/02/2013

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