Individual provider Active NPI

Mark O'Brien

  • Certified Registered Nurse Anesthetist
  • Plymouth, MN
National Provider Identifier
1124796545
Registry record updated Dec 12, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Certified Registered Nurse AnesthetistTaxonomy code 367500000X
License
238058-2 Issued in MN
Practice address
11505 39TH Ave N
Plymouth, MN 55441-1310
Phone
(612) 751-7531
NPI assigned
Aug 31, 2021
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 12, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Registered Nurse 163W00000X 238058-2 MN
Certified Registered Nurse Anesthetist 367500000X 238058-2 MN Primary

Addresses

Primary practice location

11505 39TH Ave N
Plymouth, MN 55441-1310

Mailing address

11505 39TH Ave N
Plymouth, MN 55441-1310
Phone (612) 751-7531

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL, MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20230607002631 IL Practitioner - Certified Registered Nurse Anesthetist (Crna) 4587021423 Reassigns benefits to 1 organization
I20241114002348 MN Practitioner - Certified Registered Nurse Anesthetist (Crna) 4587021423 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Certified Registered Nurse Anesthetist (Crna)
Education
Other, 2023
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Park Nicollet Methodist HospitalGroup PAC ID 7315840063, 112 clinicians

Practice addresses (Care Compare)

6500 Excelsior Blvd
St Louis Park, MN 55426-4702
Phone (952) 993-5000

Hospital & facility affiliations

  • Park Nicollet Methodist Hospital Hospital, Saint Louis Park, MN, CCN 240053

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
238058-2MNMDRegistered Nurse

Practice roles

OrganizationSpecialtyStatusNew patients
Park Nicollet Methodist Hospital CurrentSince Oct 28, 2024 Accepting new patients
Park Nicollet Methodist Hospital Nurse Anesthetist, Certified Registered CurrentSince Oct 28, 2024 Accepting new patients
Northstar Anesthesia of Illinois, LLC Nurse Anesthetist, Certified Registered CurrentSince May 30, 2023 Accepting new patients

Locations

13500 Powers Ct
Ste 230
Fort Myers, FL 33912
Phone (239) 610-0784

1423 Chicago Rd
Sauk Village, IL 60411
Phone (708) 679-2160

14700 28th Ave N
Ste 20
Plymouth, MN 55447
Phone (612) 559-3779

6500 Excelsior Blvd
St Louis Park, MN 55426
Phone (952) 993-3246

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1630368000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1702339200000",
    "number": "1124796545",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11505 39TH AVE N",
            "city": "PLYMOUTH",
            "state": "MN",
            "postal_code": "554411310",
            "telephone_number": "612-751-7531"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11505 39TH AVE N",
            "city": "PLYMOUTH",
            "state": "MN",
            "postal_code": "554411310",
            "telephone_number": "612-751-7531"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "O'BRIEN",
        "first_name": "MARK",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-08-31",
        "last_updated": "2023-12-12",
        "certification_date": "2023-12-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "MN",
            "license": "238058-2",
            "primary": false
        },
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "MN",
            "license": "238058-2",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Plymouth, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 12, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.