Provider Demographics
NPI:1508040312
Name:BROWN, PAUL ROBERT (PA C)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ROBERT
Last Name:BROWN
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 MOCKINGBIRD CT
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-4933
Mailing Address - Country:US
Mailing Address - Phone:847-316-6844
Mailing Address - Fax:
Practice Address - Street 1:2222 CHERRY ST
Practice Address - Street 2:MOB 2 - STE 1250 C/O MERCY CARDIOTHORACIC SURGICAL
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2673
Practice Address - Country:US
Practice Address - Phone:419-251-3180
Practice Address - Fax:419-251-3849
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000868363AM0700X
OH50001371363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50-001371OtherMEDICAL LICENSE
OH50-001371OtherMEDICAL LICENSE
IL205067Medicare PIN