Provider Demographics
NPI:1053398412
Name:BROWN, WENDY THOMAS (MD)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:THOMAS
Last Name:BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:ANN
Other - Last Name:THOMAS BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7272
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:3264 N EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9746
Practice Address - Country:US
Practice Address - Phone:616-363-7272
Practice Address - Fax:616-361-5828
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010529892085P0229X, 2085R0202X
MI43015018912085R0202X, 2085P0229X
TN402862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10110018OtherOPTIMA HEALTH PLAN
VA10110018OtherSENTARA HEALTH PLAN
NC180AFOtherBCBSNC
VA1053398412OtherVA PREMIER HEALTH PLAN
NC1053398412Medicaid
VA1053398412Medicaid
VA1053398412OtherTRICARE PRIME NETWORK
VAP01206178OtherRAILROAD MEDICARE
VA139178OtherBCBSVA
VA5512875OtherAETNA HEALTHCARE
VAP01206178OtherRAILROAD MEDICARE
NC1053398412Medicaid