Provider Demographics
NPI:1578646212
Name:DETAMORE-BRUSH, PATSY S (MD)
Entity Type:Individual
Prefix:
First Name:PATSY
Middle Name:S
Last Name:DETAMORE-BRUSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 S 500 W
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-8377
Mailing Address - Country:US
Mailing Address - Phone:260-726-9027
Mailing Address - Fax:260-726-9529
Practice Address - Street 1:822 S 500 W
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-8377
Practice Address - Country:US
Practice Address - Phone:260-726-9027
Practice Address - Fax:260-726-9529
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034065A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200006740Medicaid
IN200006740Medicaid
IN862280YYMedicare PIN