Healthcare Provider Details

I. General information

NPI: 1306900378
Provider Name (Legal Business Name): MATTHEW J OBRIEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N. ST. CLAIR SUITE 18-200
CHICAGO IL
60611
US

IV. Provider business mailing address

750 N. LAKE SHORE DRIVE 6TH FLOOR
CHICAGO IL
60611
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-8630
  • Fax:
Mailing address:
  • Phone: 215-573-2562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT183707
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: