Provider Demographics
NPI:1326532904
Name:O'BRIEN, CHANEL (DO)
Entity Type:Individual
Prefix:DR
First Name:CHANEL
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 CALVIN AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3232
Mailing Address - Country:US
Mailing Address - Phone:231-740-1488
Mailing Address - Fax:
Practice Address - Street 1:1521 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1640
Practice Address - Country:US
Practice Address - Phone:269-226-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314330207P00000X
MI5101027655207P00000X
PAOT018434390200000X
OH34.015540207P00000X
IN02006932A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program