Provider Demographics
NPI:1518081066
Name:BROWN ROAD FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:BROWN ROAD FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KATY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-584-3264
Mailing Address - Street 1:2310 E BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-5226
Mailing Address - Country:US
Mailing Address - Phone:480-649-9000
Mailing Address - Fax:480-248-9213
Practice Address - Street 1:2310 E BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5226
Practice Address - Country:US
Practice Address - Phone:480-649-9000
Practice Address - Fax:480-248-9213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20274305R00000X
AZ2834305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF69224Medicare UPIN
AZF03016Medicare UPIN
AZZ103791Medicare ID - Type UnspecifiedROBERT LAUFER
AZZ103790Medicare PIN
AZZ103791Medicare PIN
AZZ103790Medicare ID - Type UnspecifiedJERRY SHOCKEY