Provider Demographics
NPI: | 1164486890 |
---|---|
Name: | BROWN, STEPHEN B (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | STEPHEN |
Middle Name: | B |
Last Name: | BROWN |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1535 GULL RD STE 200 |
Mailing Address - Street 2: | |
Mailing Address - City: | KALAMAZOO |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 49048-1638 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 269-388-6350 |
Mailing Address - Fax: | 269-388-6360 |
Practice Address - Street 1: | 1535 GULL RD STE 200 |
Practice Address - Street 2: | |
Practice Address - City: | KALAMAZOO |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49048-1638 |
Practice Address - Country: | US |
Practice Address - Phone: | 269-388-6350 |
Practice Address - Fax: | 269-388-6360 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-12 |
Last Update Date: | 2018-10-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 4301056595 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 4336438 | Medicaid | |
P113493 | Other | B XBS MI | |
MI | 4336447 | Medicaid | |
MI | 4336447 | Medicaid | |
MI | N36290002 | Medicare ID - Type Unspecified | |
MI | N40860001 | Medicare ID - Type Unspecified |