Healthcare Provider Details

I. General information

NPI: 1124050182
Provider Name (Legal Business Name): CHARLES LOREN OBRIEN III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 S WAUKEGAN RD STE 100
DEERFIELD IL
60015-5204
US

IV. Provider business mailing address

49 S WAUKEGAN RD STE 100
DEERFIELD IL
60015-5204
US

V. Phone/Fax

Practice location:
  • Phone: 847-945-4575
  • Fax: 847-945-4593
Mailing address:
  • Phone: 847-945-4575
  • Fax: 847-945-4593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036057256
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: