Healthcare Provider Details

I. General information

NPI: 1255434155
Provider Name (Legal Business Name): DANIEL T OBRIEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST 11M
DETROIT MI
48201-1916
US

IV. Provider business mailing address

43350 TYLER RD
BELLEVILLE MI
48111-4330
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-3724
  • Fax:
Mailing address:
  • Phone: 313-576-3724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601001300
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: