Basic Information
| Provider Information | |||||||||
| NPI: | 1306107081 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 VICTORY DRIVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168832660 | ||||||||
| FaxNumber: | 8167929819 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 W US HIGHWAY 50 | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622082928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186246485 | ||||||||
| FaxNumber: | 6186246702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2012 | ||||||||
| LastUpdateDate: | 05/30/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 2757 | IL | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237700000X | 2008028705 | MO | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.