Healthcare Provider Details

I. General information

NPI: 1679869085
Provider Name (Legal Business Name): EDMOND O'BRIEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 11/03/2023
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 EAST MEDICAL CENTER DRIVE D3236 MPB, SPC 5718
ANN ARBOR MI
48109-5718
US

IV. Provider business mailing address

333 N SUMMIT ST FL 7
TOLEDO OH
43604-1531
US

V. Phone/Fax

Practice location:
  • Phone: 734-763-5589
  • Fax: 734-763-4208
Mailing address:
  • Phone: 877-373-0871
  • Fax: 419-885-3921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301098514
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35.136783
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: