Provider Demographics
NPI:1891833570
Name:BRIAN POWDERLY MD
Entity Type:Organization
Organization Name:BRIAN POWDERLY MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:POWDERLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-422-8112
Mailing Address - Street 1:301 SAINT ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:BELPRE
Mailing Address - State:OH
Mailing Address - Zip Code:45714-9327
Mailing Address - Country:US
Mailing Address - Phone:304-422-8112
Mailing Address - Fax:304-422-3924
Practice Address - Street 1:2675 36TH ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26104-8024
Practice Address - Country:US
Practice Address - Phone:304-422-8112
Practice Address - Fax:304-422-3924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2016-11-01
Deactivation Date:2009-07-24
Deactivation Code:
Reactivation Date:2013-01-10
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2125417Medicaid
WV3810006475Medicaid
WV9282251Medicare PIN
WV3810006475Medicaid