Provider Demographics
NPI:1609018233
Name:MARK S OBRIEN MD PLC
Entity Type:Organization
Organization Name:MARK S OBRIEN MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-774-8200
Mailing Address - Street 1:4070 LAKE DR SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8294
Mailing Address - Country:US
Mailing Address - Phone:616-774-8200
Mailing Address - Fax:616-774-0304
Practice Address - Street 1:4070 LAKE DR SE
Practice Address - Street 2:SUITE 201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8294
Practice Address - Country:US
Practice Address - Phone:616-774-8200
Practice Address - Fax:616-774-0304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048187207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty