Provider Demographics
NPI:1003876269
Name:BRINK, JEROMY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROMY
Middle Name:
Last Name:BRINK
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 1:2320 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1303
Mailing Address - Country:US
Mailing Address - Phone:602-258-9900
Mailing Address - Fax:602-258-9904
Practice Address - Street 1:6040 N 7TH ST STE 105
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-1803
Practice Address - Country:US
Practice Address - Phone:602-277-7430
Practice Address - Fax:602-279-5333
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ314912086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ793910Medicaid
AZZ111889Medicare PIN
AZH11870Medicare UPIN
AZ793910Medicaid
AZ80180Medicare ID - Type Unspecified