Provider Demographics
NPI:1114079118
Name:OBRIEN, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 W 100TH ST APT 4D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:519 W 114TH ST
Practice Address - Street 2:COLUMBIA HEALTH SERVICE MC3601
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-7036
Practice Address - Country:US
Practice Address - Phone:212-854-9842
Practice Address - Fax:212-854-9851
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140846207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00920030Medicaid
06F95Medicare ID - Type Unspecified
NY00920030Medicaid