Provider Demographics
NPI:1508998899
Name:STAEHELI, BRUCE WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:WAYNE
Last Name:STAEHELI
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 2467
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73648-2467
Mailing Address - Country:US
Mailing Address - Phone:580-303-4664
Mailing Address - Fax:
Practice Address - Street 1:119 CLUBHOUSE PL
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-7301
Practice Address - Country:US
Practice Address - Phone:580-303-4664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 072661207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1062641OtherWV DWC
OH000000561000OtherANTHEM
WV3810012159Medicaid
OH000000381808OtherANTHEM
OH2015698Medicaid
OH000000561000OtherANTHEM
OHP00461390Medicare PIN
OH000000381808OtherANTHEM
OH$$$$$$$$$-00OtherOHIO BWC
WV3810012159Medicaid