MEDICARE: PROF. MATTHEW SCOTT O'BRIEN PHD, ATC, LAT

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
1	2255A2300X	Athletic Trainer	AT-302	OK

General Provider Information

NPI Number	:	1942295316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. MATTHEW SCOTT O'BRIEN PHD, ATC, LAT

Provider Business Mailing Address
First Line	:	3108 W 30TH AVE
Second Line	:
City	:	STILLWATER
State	:	OK
Zip	:	74074-2215
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 GALLAGHER IBA HALL
Second Line	:
City	:	STILLWATER
State	:	OK
Zip	:	74078-0001
Country	:	US
Telephone Number	:	405-744-9439
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	07/08/2007

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