Healthcare Provider Details

I. General information

NPI: 1770724312
Provider Name (Legal Business Name): TRACY MED BROWN JR. EMT-P
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG. 301 ANDREW'S AVE LYSTER ARMY HEALTH CLINIC
FT. RUCKER AL
36362-5333
US

IV. Provider business mailing address

BUILDING 301 ANDREWS AVE LYSTER ARMY HEALTH CLINIC
FORT RUCKER AL
36362-5333
US

V. Phone/Fax

Practice location:
  • Phone: 334-255-2456
  • Fax:
Mailing address:
  • Phone: 334-255-0456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number0500201
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: