Provider Demographics
NPI:1750385241
Name:BRINK, THOMAS WESLEY (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:WESLEY
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 1:4444 KALAMAZOO AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-4600
Mailing Address - Country:US
Mailing Address - Phone:616-391-5600
Mailing Address - Fax:616-391-5685
Practice Address - Street 1:4444 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-4600
Practice Address - Country:US
Practice Address - Phone:616-391-5600
Practice Address - Fax:616-391-5685
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032174207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4199820Medicaid
MI4199820Medicaid
MIOD14835018Medicare ID - Type Unspecified