Provider Demographics
NPI:1437259793
Name:BRUBAKER, RUSSEL VERNE (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:VERNE
Last Name:BRUBAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-0044
Mailing Address - Country:US
Mailing Address - Phone:616-868-7115
Mailing Address - Fax:
Practice Address - Street 1:376 E APPLE AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-3466
Practice Address - Country:US
Practice Address - Phone:231-724-1111
Practice Address - Fax:231-724-3348
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010401472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRB040147OtherBCBS PIN
MI4166801Medicaid
MI4166801Medicaid