Provider Demographics
NPI:1013901396
Name:BROWN, ROGER E (CRNA)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:E
Last Name:BROWN
Suffix:
Gender:M
Credentials:CRNA
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 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:765-448-8335
Practice Address - Street 1:2600 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2479
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28122783A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200024320Medicaid
IN9425535OtherPHCS PID NUMBER
IN000000475939OtherANTHEM PROVIDER NUMBER
IN200024320Medicaid
INP00382395Medicare PIN
INR00275Medicare UPIN