Provider Demographics
NPI:1043476450
Name:M. KEVIN O'CONNOR MD LLC
Entity Type:Organization
Organization Name:M. KEVIN O'CONNOR MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-912-0200
Mailing Address - Street 1:225 MILLBURN AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1737
Mailing Address - Country:US
Mailing Address - Phone:973-912-0200
Mailing Address - Fax:973-376-8039
Practice Address - Street 1:225 MILLBURN AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1737
Practice Address - Country:US
Practice Address - Phone:973-912-0200
Practice Address - Fax:973-376-8039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07734100261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1033257431OtherNPI #
NJ085648Medicare PIN