Basic Information
| Provider Information | |||||||||
| NPI: | 1376531301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 827783 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191827783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073008 | ||||||||
| FaxNumber: | 2157071387 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 N BROAD ST | ||||||||
| Address2: | 7TH FL OUT PATIENT BLDG | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073008 | ||||||||
| FaxNumber: | 2157071387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 01/27/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD024087E | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0008666500001 | 05 | PA | MEDICAID |