=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801046958
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARSHALL F. BRUSTEIN M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2008
-----------------------------------------------------
Last Update Date | 09/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 W HAY ST SUITE 112
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526-6328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-872-8204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 W HAY ST SUITE 112
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526-6328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-872-8204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARSHALL F. BRUSTEIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 217-872-8204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 056006099
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 056005019
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 036104593
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 036104593
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------