1508040312 NPI number — MR. PAUL ROBERT BROWN PA C

Table of content: MR. PAUL ROBERT BROWN PA C (NPI 1508040312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508040312 NPI number — MR. PAUL ROBERT BROWN PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
PAUL
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA 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:
1508040312
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
449 MOCKINGBIRD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINDENHURST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60046-4933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-316-6844
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2222 CHERRY ST
Provider Second Line Business Practice Location Address:
MOB 2 - STE 1250 C/O MERCY CARDIOTHORACIC SURGICAL
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43608-2673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-251-3180
Provider Business Practice Location Address Fax Number:
419-251-3849
Provider Enumeration Date:
12/28/2007

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: 363AM0700X , with the licence number:  085000868 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AS0400X , with the licence number: 50001371 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 50-001371 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 024739900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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