Provider Demographics
NPI:1275581118
Name:BROWN, KENNETH BLAIR (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:BLAIR
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 1:7611 FOREST AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4946
Mailing Address - Country:US
Mailing Address - Phone:804-968-4435
Mailing Address - Fax:804-968-4463
Practice Address - Street 1:7611 FOREST AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4946
Practice Address - Country:US
Practice Address - Phone:804-968-4435
Practice Address - Fax:804-968-4463
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038892208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007345488Medicaid
VAVAA104106OtherMEDICARE PTAN
020000707Medicare ID - Type Unspecified
VA007345488Medicaid