Basic Information
| Provider Information | |||||||||
| NPI: | 1306259627 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUSHABER | ||||||||
| FirstName: | OLGA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KLYUCHNIKOVA | ||||||||
| OtherFirstName: | OLGA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 23133 ORCHARD LAKE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483363279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484718950 | ||||||||
| FaxNumber: | 2484719978 | ||||||||
| Practice Location | |||||||||
| Address1: | 23133 ORCHARD LAKE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483363279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484718950 | ||||||||
| FaxNumber: | 2484719978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2014 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101021269 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 5101021269 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 5101021269 | 01 | MI | MI LICENSE | OTHER |