Provider Demographics
NPI:1174527584
Name:O'BRIEN, EDWARD (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
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:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:314-851-4477
Practice Address - Street 1:9930 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-1827
Practice Address - Country:US
Practice Address - Phone:314-984-8827
Practice Address - Fax:314-984-0736
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042492085B0100X
MOMO310972085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200439495Medicaid
MO045012451Medicare ID - Type Unspecified
MO326395406Medicare PIN
MO326395405Medicare PIN
MO200439495Medicaid