Healthcare Provider Details

I. General information

NPI: 1275158677
Provider Name (Legal Business Name): SHANE BROWN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 HOSPITAL DR NE
COVINGTON GA
30014-2566
US

IV. Provider business mailing address

14960 256TH ST
ROSEDALE NY
11422-2702
US

V. Phone/Fax

Practice location:
  • Phone: 770-786-7053
  • Fax:
Mailing address:
  • Phone: 718-749-1526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number114380
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: