Provider Demographics
NPI:1891809810
Name:BROWN, RUSSELL W (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:W
Last Name:BROWN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-529-0568
Practice Address - Street 1:405 RUSHING DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3730
Practice Address - Country:US
Practice Address - Phone:618-993-3300
Practice Address - Fax:618-997-6626
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
043448OtherHEALTH ALLIANCE
IL036081556Medicaid
080129117OtherBCBS
174143OtherHEALTH LINK
10019630OtherRAILROAD MEDICARE
043448OtherHEALTH ALLIANCE
174143OtherHEALTH LINK
E26544Medicare UPIN