1780757617 NPI number — JAMES E BROWN MD

Table of content: SHANE STEAN PETERSON DO (NPI 1609439066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780757617 NPI number — JAMES E BROWN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAMES E BROWN MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780757617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2010 DOCTOR OATES DRIVE
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
MARTINSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-264-8603
Provider Business Mailing Address Fax Number:
304-264-1577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2010 DOCTOR OATES DRIVE
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
MARTINSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-264-8603
Provider Business Practice Location Address Fax Number:
304-264-1577
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
304-264-8603

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0092928000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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