Healthcare Provider Details

I. General information

NPI: 1124466222
Provider Name (Legal Business Name): TRAVIS G O'BRIEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 SMITH AVE N STE 220
SAINT PAUL MN
55102-2459
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-8295
  • Fax:
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number58143
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number58143
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number58143
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: