Provider Demographics
NPI:1467152405
Name:REEDY, BRIAN ADAM (PRSS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ADAM
Last Name:REEDY
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 WASHINGTON ST E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-2505
Mailing Address - Country:US
Mailing Address - Phone:681-661-3010
Mailing Address - Fax:
Practice Address - Street 1:1511 WASHINGTON ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-2505
Practice Address - Country:US
Practice Address - Phone:681-205-8480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty