Basic Information
| Provider Information | |||||||||
| NPI: | 1467566604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | VANCE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301C US ROUTE 1 | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040749701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073968600 | ||||||||
| FaxNumber: | 2073968632 | ||||||||
| Practice Location | |||||||||
| Address1: | 96 CAMPUS DR | ||||||||
| Address2: | SUITE 2C | ||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078837926 | ||||||||
| FaxNumber: | 2078831925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 04/16/2012 | ||||||||
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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 | 207Q00000X | 35077106B | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD18087 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2135497 | 05 | OH | MEDICAID |