Basic Information
| Provider Information | |||||||||
| NPI: | 1417199167 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNETH S BROWN MD A PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1866 NORTH ORANGE GROVE AVE. | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096204373 | ||||||||
| FaxNumber: | 9096207179 | ||||||||
| Practice Location | |||||||||
| Address1: | 1866 NORTH ORANGE GROVE AVE. | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096204373 | ||||||||
| FaxNumber: | 9096207179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2009 | ||||||||
| LastUpdateDate: | 07/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | SPIERS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9096204373 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G304560 | 05 | CA | MEDICAID |