Provider Demographics
NPI:1679538177
Name:BROWN, RICHARD SHANE (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:SHANE
Last Name:BROWN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 COOPER RD STE 440
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8055
Mailing Address - Country:US
Mailing Address - Phone:380-898-5561
Mailing Address - Fax:380-898-5563
Practice Address - Street 1:477 COOPER RD
Practice Address - Street 2:SUITE 440
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8053
Practice Address - Country:US
Practice Address - Phone:380-898-5561
Practice Address - Fax:380-898-5563
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.080268208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4811552Medicaid
MI4811552Medicaid
MI0B41012OtherBCN
MAP00273114OtherRAILROAD MEDICARE
MI0M75210Medicare ID - Type Unspecified
OH4303042Medicare PIN
MIH79375Medicare UPIN
MI4811552Medicaid
OH4303041Medicare PIN