Provider Demographics
NPI:1790012383
Name:BRIAN E O'BYRNE, M.D. P.A.
Entity Type:Organization
Organization Name:BRIAN E O'BYRNE, M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:O'BYRNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-535-4470
Mailing Address - Street 1:2860 CHANNING WAY STE 117
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7532
Mailing Address - Country:US
Mailing Address - Phone:208-535-4470
Mailing Address - Fax:208-535-4476
Practice Address - Street 1:2860 CHANNING WAY STE 117
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7532
Practice Address - Country:US
Practice Address - Phone:208-535-4470
Practice Address - Fax:208-535-4476
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIAN E O'BYRNE, M.D. P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-03
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6123208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1770822074OtherNPPES
ID1801896717OtherNPPES
ID1770822074OtherNPPES