Provider Demographics
NPI:1639706591
Name:ANDERSON, BRYCE ELWIN
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:ELWIN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
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 9149
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-9149
Mailing Address - Country:US
Mailing Address - Phone:304-293-2436
Mailing Address - Fax:304-293-6702
Practice Address - Street 1:800 WHEELING AVE
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1697
Practice Address - Country:US
Practice Address - Phone:048-453-2113
Practice Address - Fax:304-843-3202
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV31944207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program