Provider Demographics
NPI:1104096684
Name:DANIEL R BROWN
Entity type:Organization
Organization Name:DANIEL R BROWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-988-6034
Mailing Address - Street 1:101 N 16TH ST
Mailing Address - Street 2:P.O. BOX 2025
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-1750
Mailing Address - Country:US
Mailing Address - Phone:618-988-6034
Mailing Address - Fax:618-988-6479
Practice Address - Street 1:101 N 16TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-1750
Practice Address - Country:US
Practice Address - Phone:618-988-6034
Practice Address - Fax:618-988-6479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016.004890213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004890Medicaid
IL016004890Medicaid
IL4497790001Medicare NSC