Provider Demographics
NPI:1588636138
Name:O BRIEN, KEVIN (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:O BRIEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 OMNI DR
Mailing Address - Street 2:STE B
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29672-9448
Mailing Address - Country:US
Mailing Address - Phone:864-885-7881
Mailing Address - Fax:864-885-7885
Practice Address - Street 1:107 OMNI DR
Practice Address - Street 2:STE B
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9448
Practice Address - Country:US
Practice Address - Phone:864-885-7881
Practice Address - Fax:864-885-7885
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1063207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4697Medicaid
SCAA1887OtherMEDICARE PTAN
SCE500OtherMEDICARE PTAN
SC010632Medicaid
SC8768Medicare PIN