1104354612 NPI number — DR. BENJAMIN ROBERT BROWN D.C.

Table of content: DR. BENJAMIN ROBERT BROWN D.C. (NPI 1104354612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104354612 NPI number — DR. BENJAMIN ROBERT BROWN D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
BENJAMIN
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1104354612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4460 N ILLINOIS ST STE 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWANSEA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62226-1899
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-744-7314
Provider Business Mailing Address Fax Number:
618-257-3291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9449 OLIVE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLIVETTE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63132-3130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-432-2444
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2017

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: 111N00000X , with the licence number:  2017015799 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 038.013195 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com