Healthcare Provider Details

I. General information

NPI: 1568426039
Provider Name (Legal Business Name): GINA L. O'BRIEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 COURT ST
KEENE NH
03431-1719
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 603-354-5400
  • Fax:
Mailing address:
  • Phone: 800-225-8885
  • Fax: 508-334-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number205161
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0103616
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: