Provider Demographics
NPI:1942216775
Name:MCKELWAY, RUSSEL BRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:BRICK
Last Name:MCKELWAY
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 1:1 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22611-1340
Mailing Address - Country:US
Mailing Address - Phone:540-667-1230
Mailing Address - Fax:540-277-2174
Practice Address - Street 1:1 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:VA
Practice Address - Zip Code:22611-1340
Practice Address - Country:US
Practice Address - Phone:540-667-1230
Practice Address - Fax:540-277-2174
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010386622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA075075OtherANTHEM
VA7135424Medicaid
74722OtherCIGNA
D89905Medicare UPIN