Basic Information
| Provider Information | |||||||||
| NPI: | 1558360610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STUCHELL | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 63 WHARF ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265015937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042913627 | ||||||||
| FaxNumber: | 3045983630 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 WHARF ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265015937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042913627 | ||||||||
| FaxNumber: | 3045983630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 05/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 19964 | WV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5600374000 | 05 | WV | MEDICAID | WV19964B | 01 | WV | HEALTH PLAN | OTHER | 550783964004 | 01 | WV | MT STATE BCBS | OTHER |