Provider Demographics
NPI:1619126539
Name:EVAN D. O'BRIEN, M.D., P.C
Entity Type:Organization
Organization Name:EVAN D. O'BRIEN, M.D., P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-845-0707
Mailing Address - Street 1:1225 N BROAD ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-1203
Mailing Address - Country:US
Mailing Address - Phone:856-845-0707
Mailing Address - Fax:
Practice Address - Street 1:1225 N BROAD ST
Practice Address - Street 2:SUITE 3
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-1203
Practice Address - Country:US
Practice Address - Phone:856-845-0707
Practice Address - Fax:856-845-0082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA63525207XS0117X
NJ25MA077774002081P2900X
NJ25MP00100300363AS0400X
NJ25MP00021200363AS0400X
NJ26NJ00027700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6191490001Medicare NSC