Healthcare Provider Details

I. General information

NPI: 1174527584
Provider Name (Legal Business Name): EDWARD O'BRIEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9930 WATSON RD
SAINT LOUIS MO
63126-1827
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 314-984-8827
  • Fax: 314-984-0736
Mailing address:
  • Phone: 314-851-1000
  • Fax: 314-851-4477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number03604249
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMO31097
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: