Healthcare Provider Details

I. General information

NPI: 1134411192
Provider Name (Legal Business Name): SEAN THOMAS O'BRIEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S THOMPSON AVE
RUSHMORE MN
56168-9674
US

IV. Provider business mailing address

119 S THOMPSON AVE
RUSHMORE MN
56168-9674
US

V. Phone/Fax

Practice location:
  • Phone: 651-408-4980
  • Fax:
Mailing address:
  • Phone: 651-408-4980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number59208
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: