Provider Demographics
NPI:1629022538
Name:BROWN, GARY HAMILTON (PT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:HAMILTON
Last Name:BROWN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-9154
Mailing Address - Country:US
Mailing Address - Phone:270-825-2158
Mailing Address - Fax:270-825-1277
Practice Address - Street 1:121 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:KY
Practice Address - Zip Code:42078-8043
Practice Address - Country:US
Practice Address - Phone:270-988-7213
Practice Address - Fax:270-988-2199
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY000360225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8700018800Medicaid
KY000000179307OtherID BLUE CROSS BLUE SHIELD
KY000000179307OtherID BLUE CROSS BLUE SHIELD
KYP14101Medicare UPIN
KY5024001Medicare ID - Type UnspecifiedMEDICARE ID DRAFFENVILLE
KY5023701Medicare ID - Type UnspecifiedMEDICARE ID SALEM