Provider Demographics
NPI:1942214002
Name:BROWN, RODERICK BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:BENJAMIN
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 1:10 4TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-1820
Mailing Address - Country:US
Mailing Address - Phone:320-634-2215
Mailing Address - Fax:320-634-2262
Practice Address - Street 1:10 4TH AVE SE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1820
Practice Address - Country:US
Practice Address - Phone:320-634-2215
Practice Address - Fax:320-634-2262
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
39-40025OtherMEDICA
1004387OtherPREFERRED ONE
HP25406OtherHEALTH PARTNERS
110886OtherUCARE
MN4T897BROtherBLUE CROSS
01-20641OtherMEDICA
MN21082BROtherBLUE CROSS
FP0356OtherARAZ
01-08141OtherMEDICA
01-06787OtherMEDICA
D75496Medicare UPIN