Provider Demographics
NPI:1215238878
Name:CLAYTON G BROWN MD A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:CLAYTON G BROWN MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INCORPORATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:GIACOBBE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-654-0027
Mailing Address - Street 1:2335 CHURCH ST
Mailing Address - Street 2:STE F
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2700
Mailing Address - Country:US
Mailing Address - Phone:225-654-0027
Mailing Address - Fax:225-654-0052
Practice Address - Street 1:2335 CHURCH ST STE F
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2700
Practice Address - Country:US
Practice Address - Phone:225-654-0027
Practice Address - Fax:225-654-0052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014714207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB62433Medicare UPIN