Provider Demographics
NPI:1528095783
Name:O'NEILL, BRYAN J (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:J
Last Name:O'NEILL
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 1:124 DEKALB PIKE
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-1853
Mailing Address - Country:US
Mailing Address - Phone:215-699-3727
Mailing Address - Fax:215-699-9337
Practice Address - Street 1:124 DEKALB PIKE
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-1853
Practice Address - Country:US
Practice Address - Phone:215-699-3727
Practice Address - Fax:215-699-9337
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD058644L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG-61521Medicare UPIN
PA476119Medicare ID - Type Unspecified