1134111594 NPI number — BRINKS FAMILY PRACTICE PC

Table of content: (NPI 1134111594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134111594 NPI number — BRINKS FAMILY PRACTICE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRINKS FAMILY PRACTICE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134111594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCETON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47670-1516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-386-7522
Provider Business Mailing Address Fax Number:
812-386-1097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47670-1516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-386-7522
Provider Business Practice Location Address Fax Number:
812-386-1097
Provider Enumeration Date:
08/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BRINK
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
CARLTON
Authorized Official Title or Position:
PRESIDENT OF THE CORP
Authorized Official Telephone Number:
812-386-7522

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  50003963A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200066740A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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