Provider Demographics
NPI:1750508388
Name:BROWN, MICHAEL THOMAS (PAC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:BROWN
Suffix:
Gender:M
Credentials:PAC
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 MICHIGAN ST NE STE 300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2537
Practice Address - Country:US
Practice Address - Phone:616-459-7258
Practice Address - Fax:616-459-5215
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2022-03-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601004829363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N54220013Medicare PIN