Basic Information
Provider Information | |||||||||
NPI: | 1154814945 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | MORGAN WEED | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WEED | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | MORGAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6678 W THUNDERBIRD RD | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853063721 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029781500 | ||||||||
FaxNumber: | 6029780409 | ||||||||
Practice Location | |||||||||
Address1: | 6678 W THUNDERBIRD RD | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853063721 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 0297815006 | ||||||||
FaxNumber: | 6029780409 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2018 | ||||||||
LastUpdateDate: | 10/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 66518 | AZ | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
ID | Type | State | Issuer | Description | 154889 | 05 | AZ |   | MEDICAID |