Healthcare Provider Details

I. General information

NPI: 1952335606
Provider Name (Legal Business Name): MICHAEL J O'BRIEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 LONGWOOD AVE 6TH FLOOR
BOSTON MA
02115-5728
US

IV. Provider business mailing address

319 LONGWOOD AVE 6TH FLOOR
BOSTON MA
02115-5728
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-3501
  • Fax: 617-355-0176
Mailing address:
  • Phone: 617-355-3501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number213465
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: