Provider Demographics
NPI:1487634200
Name:O'BRIEN, AUTUMN M (MD)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:M
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 1:4775 KNIGHTSBRIDGE BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-4313
Mailing Address - Country:US
Mailing Address - Phone:614-442-5557
Mailing Address - Fax:614-442-1070
Practice Address - Street 1:4775 KNIGHTSBRIDGE BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-4313
Practice Address - Country:US
Practice Address - Phone:614-442-5557
Practice Address - Fax:614-442-1070
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071470207R00000X
OH35.071470208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2111048Medicaid
OH2111048Medicaid
0879844Medicare ID - Type Unspecified