Provider Demographics
NPI:1952335606
Name:O'BRIEN, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 1:319 LONGWOOD AVE
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5728
Mailing Address - Country:US
Mailing Address - Phone:617-355-3501
Mailing Address - Fax:
Practice Address - Street 1:319 LONGWOOD AVE
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5728
Practice Address - Country:US
Practice Address - Phone:617-355-3501
Practice Address - Fax:617-355-0176
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213465207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0193780Medicaid
A33986Medicare PIN
MA0193780Medicaid
H61461Medicare UPIN