Healthcare Provider Details

I. General information

NPI: 1437259793
Provider Name (Legal Business Name): RUSSEL VERNE BRUBAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 DIVISION AVE S
GRAND RAPIDS MI
49507-2480
US

IV. Provider business mailing address

PO BOX 44
ALTO MI
49302-0044
US

V. Phone/Fax

Practice location:
  • Phone: 616-247-3815
  • Fax: 616-245-0450
Mailing address:
  • Phone: 616-868-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301040147
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: