Healthcare Provider Details

I. General information

NPI: 1336185792
Provider Name (Legal Business Name): BERTUS L BROWN JR M D LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E 10TH ST SUITE A
ROLLA MO
65401-3696
US

IV. Provider business mailing address

1501 E 10TH ST SUITE A
ROLLA MO
65401-3696
US

V. Phone/Fax

Practice location:
  • Phone: 573-426-3333
  • Fax: 573-426-6666
Mailing address:
  • Phone: 573-426-3333
  • Fax: 573-426-6666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2005037955
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BERTUS L BROWN JR.
Title or Position: PHYSICIAN OWNER
Credential: M D
Phone: 573-426-3333