Healthcare Provider Details

I. General information

NPI: 1831161413
Provider Name (Legal Business Name): LISA B BROWN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 MONTGOMERY STREET
CUSTER SD
57730
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTEN MEDICAL STAFF SERVICES
RAPID CITY SD
57701-6000
US

V. Phone/Fax

Practice location:
  • Phone: 605-673-4150
  • Fax: 605-673-3917
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4882
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: