Provider Demographics
NPI:1609839356
Name:O'BRIEN, JERRY V (DO)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:V
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ANN ST NW
Mailing Address - Street 2:SUITE 209
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-2052
Mailing Address - Country:US
Mailing Address - Phone:616-808-3944
Mailing Address - Fax:616-808-3948
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:METRO HEALTH HOSPITAL
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9606
Practice Address - Country:US
Practice Address - Phone:616-808-3944
Practice Address - Fax:616-808-3948
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009941207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3318319Medicaid
MI5704503OtherBCBS PIN NUMBER
MICE1952OtherRAILROAD GROUP BILL PIN
MIJO009941OtherBCBS LICENSE NUMBER
MI5704503OtherBCBS PIN NUMBER
MIJO009941OtherBCBS LICENSE NUMBER