Healthcare Provider Details

I. General information

NPI: 1073274163
Provider Name (Legal Business Name): STEPHEN BROWN MSBS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2022
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 RICHLAND MALL
ONTARIO OH
44906-1246
US

IV. Provider business mailing address

700 N COLUMBUS ST
CRESTLINE OH
44827-1455
US

V. Phone/Fax

Practice location:
  • Phone: 419-522-3751
  • Fax:
Mailing address:
  • Phone: 419-462-3485
  • Fax: 419-462-4582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007992RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: