Basic Information
| Provider Information | |||||||||
| NPI: | 1669934311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | CORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E LANCASTER AVE | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190963450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109635444 | ||||||||
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| Practice Location | |||||||||
| Address1: | RHODE ISLAND HOSPITAL | ||||||||
| Address2: | 593 EDDY STREET | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014448809 | ||||||||
| FaxNumber: | 4014445071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2019 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | LP04921 | RI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.