Provider Demographics
NPI:1366475451
Name:PAYNE, BRYAN R (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:R
Last Name:PAYNE
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 1:1305 ELM ST E
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3861
Mailing Address - Country:US
Mailing Address - Phone:304-399-2889
Mailing Address - Fax:304-399-2881
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3800
Practice Address - Country:US
Practice Address - Phone:304-399-2889
Practice Address - Fax:304-399-2881
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22744207T00000X
LA10052R207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009223Medicaid
LA1492493Medicaid
LA5H738Medicare ID - Type Unspecified
WV4210901Medicare PIN