MEDICARE: DR. CHUCKIA NICOLE BROWN-TISDALE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	D0063718	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306836804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHUCKIA NICOLE BROWN-TISDALE M.D.

Provider Business Mailing Address
First Line	:	11116 MEDICAL CAMPUS RD
Second Line	:
City	:	HAGERSTOWN
State	:	MD
Zip	:	21742-6710
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11110 MEDICAL CAMPUS RD STE 143
Second Line	:
City	:	HAGERSTOWN
State	:	MD
Zip	:	21742-6755
Country	:	US
Telephone Number	:	301-714-4175
Fax Number	:	301-714-4183

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	01/20/2020

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