Basic Information
Provider Information | |||||||||
NPI: | 1104803907 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 103 MCKNIGHT DR | ||||||||
Address2: | SUITE A | ||||||||
City: | MIDDLETOWN | ||||||||
State: | OH | ||||||||
PostalCode: | 450444890 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132176400 | ||||||||
FaxNumber: | 5132176037 | ||||||||
Practice Location | |||||||||
Address1: | 103 MCKNIGHT DR | ||||||||
Address2: | SUITE A | ||||||||
City: | MIDDLETOWN | ||||||||
State: | OH | ||||||||
PostalCode: | 450444890 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132176400 | ||||||||
FaxNumber: | 5132176037 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2005 | ||||||||
LastUpdateDate: | 11/21/2016 | ||||||||
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 | 207RC0000X | 35063242 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 000000522401 | 01 | OH | ANTHEM BCBS | OTHER | 0882666 | 01 | OH | MOLINA HEALTHCARE OF OHIO | OTHER | 208679830027 | 01 | OH | CARESOURCE | OTHER | 283756 | 01 | OH | AMERIGROUP | OTHER | 0882666 | 05 | OH |   | MEDICAID |