Provider Demographics
NPI:1235367442
Name:O'BRYAN FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:O'BRYAN FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:O'BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-442-0240
Mailing Address - Street 1:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-0834
Practice Address - Street 1:5120 VILLAGE SQUARE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9060
Practice Address - Country:US
Practice Address - Phone:270-442-0240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-25
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01086Medicare PIN
KYDP4410Medicare PIN