Healthcare Provider Details

I. General information

NPI: 1386628170
Provider Name (Legal Business Name): MICHAEL JOSEPH O'BRIEN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 CLINGAN ROAD SUITE A
POLAND OH
44514-4202
US

IV. Provider business mailing address

6615 CLINGAN ROAD SUITE A
POLAND OH
44514-4202
US

V. Phone/Fax

Practice location:
  • Phone: 330-707-1425
  • Fax: 330-757-2814
Mailing address:
  • Phone: 330-707-1425
  • Fax: 330-757-2814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35080796
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: