Healthcare Provider Details

I. General information

NPI: 1568629699
Provider Name (Legal Business Name): ELLENMARIE ZWANK BROWN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELLEN MARIE ZWANK M.D.

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S MAIN ST
MOSCOW ID
83843-3046
US

IV. Provider business mailing address

700 S MAIN ST
MOSCOW ID
83843-3046
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-4511
  • Fax: 318-329-4719
Mailing address:
  • Phone: 208-882-4511
  • Fax: 318-329-4719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM-14901
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: