Provider Demographics
NPI:1760479257
Name:NEELY, BRIAN S (MD)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:S
Last Name:NEELY
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 1:611 WATKINS CENTRE PKWY STE 350
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-4404
Mailing Address - Country:US
Mailing Address - Phone:804-601-4901
Mailing Address - Fax:866-674-0063
Practice Address - Street 1:611 WATKINS CENTRE PKWY STE 350
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-4404
Practice Address - Country:US
Practice Address - Phone:804-601-4901
Practice Address - Fax:866-674-0063
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101228375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5640997Medicaid
H28086Medicare UPIN
VA5640997Medicaid