Healthcare Provider Details

I. General information

NPI: 1467527655
Provider Name (Legal Business Name): JOHN GERARD OBRIEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 OSWEGO ROAD SUITE 220
LIVERPOOL NY
13090
US

IV. Provider business mailing address

8100 OSWEGO ROAD SUITE 220
LIVERPOOL NY
13090
US

V. Phone/Fax

Practice location:
  • Phone: 315-652-6551
  • Fax: 315-652-9698
Mailing address:
  • Phone: 315-652-6551
  • Fax: 315-652-9698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number171189
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: