Healthcare Provider Details

I. General information

NPI: 1184190829
Provider Name (Legal Business Name): MATTHEW DEAN BROWN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2018
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 W MAIN ST
FAIRFIELD IL
62837-2308
US

IV. Provider business mailing address

PO BOX 155
CHRISTOPHER IL
62822-0155
US

V. Phone/Fax

Practice location:
  • Phone: 618-842-4470
  • Fax:
Mailing address:
  • Phone: 618-724-1624
  • Fax: 618-724-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.007282
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: