Healthcare Provider Details

I. General information

NPI: 1174243976
Provider Name (Legal Business Name): MARK CHARLES O'BRIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN ST
LEWISTON ME
04240-7041
US

IV. Provider business mailing address

121 WHITNEY RD
GRAY ME
04039-7507
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-0111
  • Fax:
Mailing address:
  • Phone: 207-653-3036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA253086
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: