Basic Information
| Provider Information | |||||||||
| NPI: | 1750382297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACAULAY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1602 HARPER RD | ||||||||
| Address2: | |||||||||
| City: | BECKLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258013310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047576999 | ||||||||
| FaxNumber: | 3047573252 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 HILLS PLZ | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253872438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047204466 | ||||||||
| FaxNumber: | 3047204815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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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 | 207Q00000X | 14811 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14811 | 01 | HEALTH PLAN OF UPPER OH V | OTHER | 55035705700 | 01 | WV | WV COMPENSATION | OTHER | 0052239000 | 05 | WV | MEDICAID | 001718160 | 01 | MOUNTAIN STATE BCBS | OTHER | 2043621 | 05 | OH | MEDICAID |