Healthcare Provider Details

I. General information

NPI: 1326741430
Provider Name (Legal Business Name): RUSSEL BRUBAKER MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11751 RURAL ACRES DR SE
ALTO MI
49302-9577
US

IV. Provider business mailing address

PO BOX 140241
GRAND RAPIDS MI
49514-0241
US

V. Phone/Fax

Practice location:
  • Phone: 616-868-7115
  • Fax:
Mailing address:
  • Phone: 616-868-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: VALERIE ALEXANDER
Title or Position: BILLING MANAGER
Credential:
Phone: 616-735-1505