Healthcare Provider Details

I. General information

NPI: 1366454621
Provider Name (Legal Business Name): GRAEL O'BRIEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 COVENTRY ST BURGDORF CLINIC - 2ND FLOOR ADMINISTRATION
HARTFORD CT
06112-1548
US

IV. Provider business mailing address

131 COVENTRY ST BURGDORF CLINIC - 2ND FLOOR ADMINISTRATION
HARTFORD CT
06112-1548
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-3690
  • Fax: 860-714-8683
Mailing address:
  • Phone: 860-714-3690
  • Fax: 860-714-8683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number039887
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: