Provider Demographics
NPI:1063463917
Name:O'BRIEN, JAMES GERARD (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:GERARD
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E BROADWAY
Mailing Address - Street 2:SUITE 290
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1785
Mailing Address - Country:US
Mailing Address - Phone:502-217-8221
Mailing Address - Fax:502-217-5056
Practice Address - Street 1:215 CENTRAL AVE
Practice Address - Street 2:110
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1449
Practice Address - Country:US
Practice Address - Phone:502-852-5205
Practice Address - Fax:502-852-5405
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32582207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64325822Medicaid
IN200113250Medicaid
IN200113250Medicaid
KY0631227Medicare PIN
KY00852001Medicare PIN
KY0048428Medicare PIN