Basic Information
| Provider Information | |||||||||
| NPI: | 1770570236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | BENNIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1705 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309031705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067747263 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 447 N BELAIR RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308093091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068542222 | ||||||||
| FaxNumber: | 7068542223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 02/05/2015 | ||||||||
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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 | 207Q00000X | 18711 | MS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 065085 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 08636876 | 05 | MS | MEDICAID | 003139672C | 05 | GA | MEDICAID |