Basic Information
Provider Information | |||||||||
NPI: | 1770882920 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | JOEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 282 WASHINGTON ST STE 1A | ||||||||
Address2: |   | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061063322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8605459100 | ||||||||
FaxNumber: | 8605459095 | ||||||||
Practice Location | |||||||||
Address1: | 282 WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061063322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8605459000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2011 | ||||||||
LastUpdateDate: | 11/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | A150363 | CA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XP3100X | 56697 | AZ | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207XP3100X | 69374 | CT | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
ID Information
ID | Type | State | Issuer | Description | 56697 | 05 | AZ |   | MEDICAID | 69374 | 05 | CT |   | MEDICAID |