Healthcare Provider Details

I. General information

NPI: 1376122440
Provider Name (Legal Business Name): THOMAS J O'BRIEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 01/16/2026
Certification Date: 01/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 N RANDOLPH ST
CHAMPAIGN IL
61820-3949
US

IV. Provider business mailing address

206 N RANDOLPH ST
CHAMPAIGN IL
61820-3949
US

V. Phone/Fax

Practice location:
  • Phone: 833-351-8255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125.078382
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.170923
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: