Provider Demographics
NPI:1326741430
Name:RUSSEL BRUBAKER MD
Entity Type:Organization
Organization Name:RUSSEL BRUBAKER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-735-1505
Mailing Address - Street 1:PO BOX 140241
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49514-0241
Mailing Address - Country:US
Mailing Address - Phone:616-868-7115
Mailing Address - Fax:
Practice Address - Street 1:11751 RURAL ACRES DR SE
Practice Address - Street 2:
Practice Address - City:ALTO
Practice Address - State:MI
Practice Address - Zip Code:49302-9577
Practice Address - Country:US
Practice Address - Phone:616-868-7115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty