Provider Demographics
NPI:1205808276
Name:O'BRIEN, EDWARD THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:THOMAS
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 N OLD TRL
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-8381
Mailing Address - Country:US
Mailing Address - Phone:570-374-8555
Mailing Address - Fax:570-374-9933
Practice Address - Street 1:1575 N OLD TRL
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-8381
Practice Address - Country:US
Practice Address - Phone:570-374-8555
Practice Address - Fax:570-374-9933
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024174E207RX0202X
NY235282-1207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00949440Medicaid
PACC9269OtherRR MEDICARE GROUP
PAGU039841OtherPA MEDICARE GROUP
PA0010399860010Medicaid
PAP00127810OtherRR MEDICARE PIN
PACC9269OtherRR MEDICARE GROUP
C31691Medicare UPIN
PA143645N82Medicare PIN