1790889178 NPI number — DR. ANNETTE RENAE CLARK-BROWN M.D.

Table of content: DR. ANNETTE RENAE CLARK-BROWN M.D. (NPI 1790889178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790889178 NPI number — DR. ANNETTE RENAE CLARK-BROWN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK-BROWN
Provider First Name:
ANNETTE
Provider Middle Name:
RENAE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1790889178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 8TH DIVISION RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29207-5700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-751-2553
Provider Business Mailing Address Fax Number:
803-751-0473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 STUART STREET
Provider Second Line Business Practice Location Address:
USA MEDDAC
Provider Business Practice Location Address City Name:
FORT JACKSON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-751-2234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2006

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:  27523 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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