Provider Demographics
NPI:1568629699
Name:BROWN, ELLENMARIE ZWANK (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLENMARIE
Middle Name:ZWANK
Last Name:BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MARIE
Other - Last Name:ZWANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3046
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:318-329-4719
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3046
Practice Address - Country:US
Practice Address - Phone:208-882-4511
Practice Address - Fax:318-329-4719
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14901207R00000X
LAMD.204574207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA06488Medicaid