Basic Information
| Provider Information | |||||||||
| NPI: | 1285686766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6247 | ||||||||
| Address2: | |||||||||
| City: | SNOWMASS VILLAGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816156247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438164549 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1326 EISENHOWER DR BLDG 1 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126914200 | ||||||||
| FaxNumber: | 9123033506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 19165 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 48081 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 028509 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 10025709000 | 05 | NE | MEDICAID | 52237053005 | 01 | GA | BCBS | OTHER | CO305926 | 01 | CO | MEDICARE RIA | OTHER | 200627500A | 05 | KS | MEDICAID | 85588555 | 05 | CO | MEDICAID | 1285686766 | 05 | MT | MEDICAID | 84059792913 | 05 | NE | MEDICAID | 1285686766 | 05 | WY | MEDICAID | N355708 | 01 | GA | WELLCARE | OTHER | P00347630 | 01 | RR MEDICARE | OTHER | 000321087G | 05 | GA | MEDICAID | 474618 | 05 | AZ | MEDICAID | 47706252 | 05 | NM | MEDICAID | 84089712600 | 05 | NE | MEDICAID | CO305925 | 01 | CO | MEDICARE MIC | OTHER | P00760022 | 01 | CO | RR MCR MIC | OTHER |