Healthcare Provider Details

I. General information

NPI: 1003920034
Provider Name (Legal Business Name): RUSSELL W BROWN II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 S HOSPITAL DR
MURPHYSBORO IL
62966-3333
US

IV. Provider business mailing address

109 CALIFORNIA ST PO BOX 577
CARTERVILLE IL
62918-0577
US

V. Phone/Fax

Practice location:
  • Phone: 618-519-9200
  • Fax: 618-687-1859
Mailing address:
  • Phone: 618-519-9200
  • Fax: 618-985-4635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085002271
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: