Provider Demographics
NPI:1295228161
Name:BRUCETON FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:BRUCETON FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALYSIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN,FNP-BC
Authorized Official - Phone:304-379-7600
Mailing Address - Street 1:PO BOX 442
Mailing Address - Street 2:
Mailing Address - City:BRUCETON MILLS
Mailing Address - State:WV
Mailing Address - Zip Code:26525-0442
Mailing Address - Country:US
Mailing Address - Phone:304-379-7600
Mailing Address - Fax:304-379-7599
Practice Address - Street 1:198 MORGANTOWN ST STE 2
Practice Address - Street 2:
Practice Address - City:BRUCETON MILLS
Practice Address - State:WV
Practice Address - Zip Code:26525
Practice Address - Country:US
Practice Address - Phone:304-379-7600
Practice Address - Fax:304-379-7599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-14
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV52464207Q00000X
WV81124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810029631Medicaid