Provider Demographics
NPI:1639254410
Name:RICHARD LEE OBRIEN DO PC
Entity Type:Organization
Organization Name:RICHARD LEE OBRIEN DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:315-724-8888
Mailing Address - Street 1:2614 GENESEE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6003
Mailing Address - Country:US
Mailing Address - Phone:315-724-8888
Mailing Address - Fax:315-735-2641
Practice Address - Street 1:2614 GENESEE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6003
Practice Address - Country:US
Practice Address - Phone:315-724-8888
Practice Address - Fax:315-735-2641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH36763Medicare UPIN
NYBA0515Medicare PIN