Provider Demographics
NPI:1861577959
Name:O'BRIEN, KATHLEEN B (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:B
Last Name:O'BRIEN
Suffix:
Gender:F
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 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6201
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:160 E ERIE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-1011
Practice Address - Country:US
Practice Address - Phone:215-427-3131
Practice Address - Fax:215-427-8782
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069374L2080S0010X, 208000000X, 208M00000X
DEC10007503208000000X, 2080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3270009Medicaid
NJ8283206Medicaid
DE01812378 (PA)Medicaid
PA001812378Medicaid
PA001812378Medicaid
NJ8283206Medicaid