Provider Demographics
NPI:1366852261
Name:BRENWALT, AMY MOYERS (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MOYERS
Last Name:BRENWALT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:MOYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6040 UNIVERSITY TOWN CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-2421
Mailing Address - Country:US
Mailing Address - Phone:304-598-6900
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY TOWN CENTRE - SLEETH FAMILY MEDICINE
Practice Address - Street 2:6040 UNIVERSITY TOWN CENTRE DR
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-2421
Practice Address - Country:US
Practice Address - Phone:855-988-2273
Practice Address - Fax:304-285-7372
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26746207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1236571Medicaid
PA103398958Medicaid
WV1366852261Medicaid
OH0234573Medicaid