Basic Information
| Provider Information | |||||||||
| NPI: | 1689608333 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | 2ND FLOOR, SOUTH PAVILION | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156623606 | ||||||||
| FaxNumber: | 2153495579 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | 2ND FLOOR, SOUTH PAVILION | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156623606 | ||||||||
| FaxNumber: | 2153495579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/21/2015 | ||||||||
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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 | 2084N0400X | MD015829E | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 008921220001 | 05 | PA | MEDICAID |