Healthcare Provider Details

I. General information

NPI: 1801810676
Provider Name (Legal Business Name): KEVIN J OBRIEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8433 HARCOURT RD STE 100
INDIANAPOLIS IN
46260-2193
US

IV. Provider business mailing address

1200 W WHITE RIVER BLVD
MUNCIE IN
47303-4988
US

V. Phone/Fax

Practice location:
  • Phone: 317-583-7600
  • Fax:
Mailing address:
  • Phone: 877-668-5621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10000356A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: