Healthcare Provider Details

I. General information

NPI: 1104826379
Provider Name (Legal Business Name): BLAIZE OBRIEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

974 BETHEL RD STE A
COLUMBUS OH
43214-2467
US

IV. Provider business mailing address

1810 MACKENZIE DR FL 2
COLUMBUS OH
43220-2967
US

V. Phone/Fax

Practice location:
  • Phone: 614-538-2424
  • Fax: 614-538-2418
Mailing address:
  • Phone: 614-273-2250
  • Fax: 614-273-2255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number35.076493
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: