Healthcare Provider Details

I. General information

NPI: 1336129790
Provider Name (Legal Business Name): STEPHEN FITZSIMMONS BROWN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1767 QUINCY AVE
DUNMORE PA
18509-2132
US

IV. Provider business mailing address

1767 QUINCY AVE
DUNMORE PA
18509-2132
US

V. Phone/Fax

Practice location:
  • Phone: 570-341-5544
  • Fax: 570-341-5545
Mailing address:
  • Phone: 570-341-5544
  • Fax: 570-341-5545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberDC0004338-L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0012212490002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: