Provider Demographics
NPI:1801896717
Name:O'BYRNE, BRIAN E (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:E
Last Name:O'BYRNE
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 1:2860 CHANNING WAY
Mailing Address - Street 2:STE 117
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7532
Mailing Address - Country:US
Mailing Address - Phone:208-535-4470
Mailing Address - Fax:208-535-4476
Practice Address - Street 1:2860 CHANNING WAY
Practice Address - Street 2:STE 117
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7532
Practice Address - Country:US
Practice Address - Phone:208-523-2470
Practice Address - Fax:208-523-1118
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2010-12-22
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
IDM6123208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000084200Medicaid
E6123Medicare UPIN
ID000084200Medicaid