Provider Demographics
NPI:1821165978
Name:BRUSTEIN, MARSHALL F (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:F
Last Name:BRUSTEIN
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 1:304 W HAY ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-6328
Mailing Address - Country:US
Mailing Address - Phone:217-872-8204
Mailing Address - Fax:217-872-4897
Practice Address - Street 1:304 W HAY ST
Practice Address - Street 2:SUITE 112
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6328
Practice Address - Country:US
Practice Address - Phone:217-872-8204
Practice Address - Fax:217-872-4897
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104593332B00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104593Medicaid
IL202268Medicare PIN
IL036104593Medicaid
ILH17105Medicare UPIN