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NPI Code Detail

MEDICARE: KELLY OBRIEN RD, NC

MEDICARE: KELLY OBRIEN RD, NC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208D00000XGeneral Practice PhysicianND 53CA

General Provider Information

NPI Number : 1194042721
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY OBRIEN RD, NC
Provider Business Mailing Address
First Line : 723 241ST LN SE
Second Line :
City : SAMMAMISH
State : WA
Zip : 98074-3682
Country : US
Telephone Number : 520-820-4226
Fax Number :
Provider Business Practice Location Address
First Line : 4500 9TH AVE NE STE 300
Second Line :
City : SEATTLE
State : WA
Zip : 98105-4762
Country : US
Telephone Number : 206-853-0534
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/21/2010
Last Update Date : 05/13/2024

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Directions to “ KELLY OBRIEN RD, NC” Practice Location

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