Provider Demographics
NPI:1881730331
Name:O'BRIEN, ERIN P (PA)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:P
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:P
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:175 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2670
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-649-5302
Practice Address - Street 1:175 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2670
Practice Address - Country:US
Practice Address - Phone:309-647-0201
Practice Address - Fax:309-649-5302
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0062839OtherUMWA
IL02922981OtherBCBS
IL200397OtherBLACK LUNG
IL1942315197OtherNPI CLINIC NUMBER
ILCG5172OtherRR MEDICARE GROUP
ILCG5172OtherRR MEDICARE GROUP