Healthcare Provider Details

I. General information

NPI: 1194010165
Provider Name (Legal Business Name): MR. ROBERT THOMAS BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11055 EMERALD CT
ROLLA MO
65401-9344
US

IV. Provider business mailing address

11055 EMERALD CT
ROLLA MO
65401-9344
US

V. Phone/Fax

Practice location:
  • Phone: 573-308-9999
  • Fax:
Mailing address:
  • Phone: 573-308-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number3SM647
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: