Provider Demographics
NPI:1871523977
Name:O'BRIEN, BERNARD J (PAC)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:J
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-2929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11745 US HIGHWAY 23 S
Practice Address - Street 2:
Practice Address - City:OSSINEKE
Practice Address - State:MI
Practice Address - Zip Code:49766-9582
Practice Address - Country:US
Practice Address - Phone:989-471-2156
Practice Address - Fax:989-471-5257
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R67124Medicare UPIN