Healthcare Provider Details

I. General information

NPI: 1942496252
Provider Name (Legal Business Name): ELLA E M BROWN CHARITABLE CIRCLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N MADISON ST
MARSHALL MI
49068-1143
US

IV. Provider business mailing address

200 N MADISON ST
MARSHALL MI
49068-1143
US

V. Phone/Fax

Practice location:
  • Phone: 269-781-4271
  • Fax:
Mailing address:
  • Phone: 269-781-4271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. COLLEEN M KOPPENHAVER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 269-789-3921