Provider Demographics
NPI:1477535607
Name:BROWN, RANDY M (MPT)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:M
Last Name:BROWN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:MATTHEW
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MPT
Mailing Address - Street 1:353 BLACKBURN AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-3479
Mailing Address - Country:US
Mailing Address - Phone:606-615-1774
Mailing Address - Fax:
Practice Address - Street 1:2700 GREENUP AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-1953
Practice Address - Country:US
Practice Address - Phone:800-609-0905
Practice Address - Fax:800-609-0801
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004537225100000X
OHPT 010979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8700162400Medicaid
OHBR4153341Medicare PIN
KYP00111537Medicare PIN
KY8700162400Medicaid
KY5024407Medicare PIN