Provider Demographics
NPI:1295726248
Name:BROWN, PENNY R
Entity type:Individual
Prefix:MS
First Name:PENNY
Middle Name:R
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N HENDERSON ST
Mailing Address - Street 2:STE A
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-3596
Mailing Address - Country:US
Mailing Address - Phone:309-342-8676
Mailing Address - Fax:309-342-8676
Practice Address - Street 1:430 N HENDERSON ST
Practice Address - Street 2:STE A
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-3596
Practice Address - Country:US
Practice Address - Phone:309-342-8676
Practice Address - Fax:309-342-8676
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5454400001Medicare NSC