Provider Demographics
NPI:1336185792
Name:BERTUS L BROWN JR M D LLC
Entity Type:Organization
Organization Name:BERTUS L BROWN JR M D LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERTUS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:JR
Authorized Official - Credentials:M D
Authorized Official - Phone:573-426-3333
Mailing Address - Street 1:1501 E 10TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3696
Mailing Address - Country:US
Mailing Address - Phone:573-426-3333
Mailing Address - Fax:573-426-6666
Practice Address - Street 1:1501 E 10TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3696
Practice Address - Country:US
Practice Address - Phone:573-426-3333
Practice Address - Fax:573-426-6666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005037955207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC13837Medicare UPIN