Provider Demographics
NPI:1134218662
Name:BROWN, RANDY G (MD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:G
Last Name:BROWN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:190 SCENIC VIEW LN
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-8136
Mailing Address - Country:US
Mailing Address - Phone:573-335-4601
Mailing Address - Fax:
Practice Address - Street 1:1723 BROADWAY
Practice Address - Street 2:SUITE 310
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701
Practice Address - Country:US
Practice Address - Phone:573-331-6333
Practice Address - Fax:573-331-7879
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110363208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208252122Medicaid
MO208252122Medicaid
011013435Medicare ID - Type Unspecified