Basic Information
| Provider Information | |||||||||
| NPI: | 1891833570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIAN POWDERLY MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 SAINT ANDREWS BLVD | ||||||||
| Address2: | |||||||||
| City: | BELPRE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457149327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044228112 | ||||||||
| FaxNumber: | 3044223924 | ||||||||
| Practice Location | |||||||||
| Address1: | 2675 36TH ST | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261048024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044228112 | ||||||||
| FaxNumber: | 3044223924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 11/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/24/2009 | ||||||||
| NPIReactivationDate: | 01/10/2013 | ||||||||
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| AuthorizedOfficialLastName: | POWDERLY | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3044228112 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2125417 | 05 | OH | MEDICAID | 3810006475 | 05 | WV | MEDICAID |