Provider Demographics
NPI:1366459299
Name:POLICANO, BRIAN CHRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHRISTOPHER
Last Name:POLICANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 763
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0763
Mailing Address - Country:US
Mailing Address - Phone:800-541-4009
Mailing Address - Fax:
Practice Address - Street 1:7 CHENOWETH DR
Practice Address - Street 2:SUITE A
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1887
Practice Address - Country:US
Practice Address - Phone:304-842-5777
Practice Address - Fax:304-842-3318
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV21260208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV01720854OtherBC/BS
WV3004243000Medicaid