Provider Demographics
NPI: | 1497822134 |
---|---|
Name: | BROWN, THOMAS CHANDLER (PT) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | THOMAS |
Middle Name: | CHANDLER |
Last Name: | BROWN |
Suffix: | |
Gender: | M |
Credentials: | PT |
Other - Prefix: | MR |
Other - First Name: | CHAN |
Other - Middle Name: | |
Other - Last Name: | BROWN |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | PT |
Mailing Address - Street 1: | 206B OXFORD RD |
Mailing Address - Street 2: | |
Mailing Address - City: | NEW ALBANY |
Mailing Address - State: | MS |
Mailing Address - Zip Code: | 38652-3115 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 662-534-4445 |
Mailing Address - Fax: | 662-534-9449 |
Practice Address - Street 1: | 3437 TUPELO COMMONS |
Practice Address - Street 2: | SUITE 102 |
Practice Address - City: | TUPELO |
Practice Address - State: | MS |
Practice Address - Zip Code: | 38804-9791 |
Practice Address - Country: | US |
Practice Address - Phone: | 662-680-3200 |
Practice Address - Fax: | 662-680-5090 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-11-29 |
Last Update Date: | 2009-03-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MS | PT3177 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MS | 582681044 | Other | TAX ID # |
MS | 00138736 | Medicaid | |
MS | 256599 | Medicare ID - Type Unspecified | MEDICARE ID |