Basic Information
Provider Information | |||||||||
NPI: | 1063591857 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | DOUGLAS | ||||||||
MiddleName: | THORBURN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 353 FAIRMONT BLVD | ||||||||
Address2: | ATTEN CHRISTIE MSS | ||||||||
City: | RAPID CITY | ||||||||
State: | SD | ||||||||
PostalCode: | 577017350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2073512478 | ||||||||
FaxNumber: | 2073512153 | ||||||||
Practice Location | |||||||||
Address1: | 2929 5TH STREET | ||||||||
Address2: | 240 | ||||||||
City: | RAPID CITY | ||||||||
State: | SD | ||||||||
PostalCode: | 577017338 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053413770 | ||||||||
FaxNumber: | 6053418692 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/03/2006 | ||||||||
LastUpdateDate: | 09/30/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 014738 | ME | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 8308 | SD | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 241180099 | 05 | ME |   | MEDICAID |