Provider Demographics
NPI:1275599987
Name:BREWER, JIM ED (MD)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:ED
Last Name:BREWER
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 1:722 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015
Mailing Address - Country:US
Mailing Address - Phone:501-315-0059
Mailing Address - Fax:501-315-0083
Practice Address - Street 1:722 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015
Practice Address - Country:US
Practice Address - Phone:501-315-0059
Practice Address - Fax:501-315-0083
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3951208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154130001Medicaid
ARI04577Medicare UPIN
AR5M833Medicare PIN