Healthcare Provider Details

I. General information

NPI: 1841221348
Provider Name (Legal Business Name): MARK E OBRIEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 M 139
BENTON HARBOR MI
49022-3881
US

IV. Provider business mailing address

50 INDUSTRIAL PARK DRIVE
BANGOR MI
49013
US

V. Phone/Fax

Practice location:
  • Phone: 269-927-5400
  • Fax: 269-927-5493
Mailing address:
  • Phone: 269-427-7937
  • Fax: 269-427-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301080677
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301080677
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: