Basic Information
| Provider Information | |||||||||
| NPI: | 1689674749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LESLIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1405 78TH ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | VICTORIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553869723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524433710 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2014 S 6TH ST | ||||||||
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| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564014529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188297812 | ||||||||
| FaxNumber: | 2188299751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 26923 | MN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 572282900 | 05 | MN | MEDICAID |