1942214002 NPI number — RODERICK BENJAMIN BROWN M.D.

Table of content: SHANKAR EZOM (NPI 1669191979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942214002 NPI number — RODERICK BENJAMIN BROWN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
RODERICK
Provider Middle Name:
BENJAMIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1942214002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 4TH AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENWOOD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56334-1820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-634-2215
Provider Business Mailing Address Fax Number:
320-634-2262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 4TH AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENWOOD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56334-1820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-634-2215
Provider Business Practice Location Address Fax Number:
320-634-2262
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  26202 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39-40025 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1004387 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP25406 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110886 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4T897BR . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01-20641 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21082BR . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: FP0356 . This is a "ARAZ" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01-08141 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01-06787 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".




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