Provider Demographics
NPI:1134111594
Name:BRINKS FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:BRINKS FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF THE CORP
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:CARLTON
Authorized Official - Last Name:BRINK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-386-7522
Mailing Address - Street 1:410 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IN
Mailing Address - Zip Code:47670-1516
Mailing Address - Country:US
Mailing Address - Phone:812-386-7522
Mailing Address - Fax:812-386-1097
Practice Address - Street 1:410 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-1516
Practice Address - Country:US
Practice Address - Phone:812-386-7522
Practice Address - Fax:812-386-1097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50003963A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200066740AMedicaid
IN200066740AMedicaid