Healthcare Provider Details

I. General information

NPI: 1124477237
Provider Name (Legal Business Name): KEVIN T BROWN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

IV. Provider business mailing address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-7272
  • Fax: 616-361-5828
Mailing address:
  • Phone: 616-363-7272
  • Fax: 616-361-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number036.156081
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301502688
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: