Healthcare Provider Details

I. General information

NPI: 1891809810
Provider Name (Legal Business Name): RUSSELL W BROWN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 RUSHING DR
HERRIN IL
62948-3730
US

IV. Provider business mailing address

PO BOX 1105
INDIANAPOLIS IN
46206-1105
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-3300
  • Fax: 618-997-6626
Mailing address:
  • Phone: 618-549-5361
  • Fax: 618-529-0568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036081556
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: