Provider Demographics
NPI:1437259793
Name:BRUBAKER, RUSSEL VERNE (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:VERNE
Last Name:BRUBAKER
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:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-0044
Mailing Address - Country:US
Mailing Address - Phone:616-868-7115
Mailing Address - Fax:
Practice Address - Street 1:1939 DIVISION AVE S
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-2480
Practice Address - Country:US
Practice Address - Phone:616-247-3815
Practice Address - Fax:616-245-0450
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010401472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4166801Medicaid
MIRB040147OtherBCBS PIN
MI4166801Medicaid