Provider Demographics
NPI:1003592148
Name:VERBRUGGE, MAXWELL
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:VERBRUGGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3285 SCHUST RD APT 208
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-8101
Mailing Address - Country:US
Mailing Address - Phone:616-558-3061
Mailing Address - Fax:
Practice Address - Street 1:1632 STONE ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602
Practice Address - Country:US
Practice Address - Phone:989-746-7504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program