Basic Information
| Provider Information | |||||||||
| NPI: | 1558444133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | TONYA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 MICHIGAN AVE | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | LOGANSPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469471580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5747224921 | ||||||||
| FaxNumber: | 5747390520 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 MICHIGAN AVE | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | LOGANSPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469471580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5747224921 | ||||||||
| FaxNumber: | 5747390520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 04/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01052818 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200402320 | 05 | IN | MEDICAID | 000000915720 | 01 | IN | ANTHEM | OTHER | P01428204 | 01 | IN | RR MEDICARE | OTHER |