Basic Information
| Provider Information | |||||||||
| NPI: | 1912387283 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 FARAON ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645063512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162711066 | ||||||||
| FaxNumber: | 8162716786 | ||||||||
| Practice Location | |||||||||
| Address1: | 5325 FARAON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645063488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162716122 | ||||||||
| FaxNumber: | 8162716019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2022025327 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110135305A | 05 | MA | MEDICAID |