Basic Information
Provider Information | |||||||||
NPI: | 1255436549 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN-BEBOW | ||||||||
FirstName: | VERONA | ||||||||
MiddleName: | TICE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4196 HIGHWAY 62 412 STE A | ||||||||
Address2: |   | ||||||||
City: | HARDY | ||||||||
State: | AR | ||||||||
PostalCode: | 725428002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8708561202 | ||||||||
FaxNumber: | 8708562107 | ||||||||
Practice Location | |||||||||
Address1: | 11005 HEBER SPRINGS RD N | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | AR | ||||||||
PostalCode: | 725239561 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8442914901 | ||||||||
FaxNumber: | 8708952164 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2006 | ||||||||
LastUpdateDate: | 01/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C6130 | AR | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 102751001 | 05 | AR |   | MEDICAID |