Provider Demographics
NPI:1679659866
Name:BROWN, ROGER G (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:G
Last Name:BROWN
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 1:1297 BURNS WAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901
Mailing Address - Country:US
Mailing Address - Phone:406-752-1404
Mailing Address - Fax:406-752-4263
Practice Address - Street 1:1297 BURNS WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901
Practice Address - Country:US
Practice Address - Phone:406-752-1404
Practice Address - Fax:406-752-4263
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT43402086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT057642Medicaid
D32657Medicare UPIN