Provider Demographics
NPI:1255324810
Name:BREWER, RANDALL JACKSON (MD)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:JACKSON
Last Name:BREWER
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 1:1937 AVIARA DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421
Mailing Address - Country:US
Mailing Address - Phone:423-553-6012
Mailing Address - Fax:423-490-0140
Practice Address - Street 1:1937 AVIARA DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:423-553-6012
Practice Address - Fax:423-490-0140
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN0102332084P0800X
GAGA0302742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A98406Medicare UPIN
3020416Medicare ID - Type Unspecified