1811390537 NPI number — DANIEL R BROWN

Table of content: (NPI 1811390537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811390537 NPI number — DANIEL R BROWN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DANIEL R BROWN
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:
1811390537
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 N 16TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERRIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62948-1750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-988-6034
Provider Business Mailing Address Fax Number:
618-988-6479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 SMALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRISBURG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62946-3319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-294-8466
Provider Business Practice Location Address Fax Number:
618-252-2434
Provider Enumeration Date:
10/08/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PROVIDER OWNER
Authorized Official Telephone Number:
618-988-6034

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  016004890 , 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)

  • Identifier: 016004890 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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