=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326095399
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LON RUSSELL BREWER D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2006
-----------------------------------------------------
Last Update Date | 06/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1924 NW 88TH CT
-----------------------------------------------------
City | CLIVE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50325-5463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-237-3974
-----------------------------------------------------
Fax | 515-883-2692
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2213 GRAND AVE
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50312-5305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-237-3974
-----------------------------------------------------
Fax | 515-883-2692
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01444
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------