Provider Demographics
NPI:1770570400
Name:O'BRYAN, JOSEPH M (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:O'BRYAN
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:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-0834
Practice Address - Street 1:5120 VILLAGE SQUARE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9060
Practice Address - Country:US
Practice Address - Phone:270-442-0240
Practice Address - Fax:270-442-9599
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36713207P00000X, 207Q00000X
IN01044033A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64880495Medicaid
G24312Medicare UPIN
KY0092121Medicare PIN
KY1086001Medicare PIN
KYP00757654Medicare PIN