Provider Demographics
NPI:1942263710
Name:BREARLY, WAYNE R (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:R
Last Name:BREARLY
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 1:127 KNOXLYN FARM DR
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-2738
Mailing Address - Country:US
Mailing Address - Phone:610-444-1829
Mailing Address - Fax:
Practice Address - Street 1:1700 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7529
Practice Address - Country:US
Practice Address - Phone:717-272-6621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2012-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0009272208600000X
PAMD032858E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C30568Medicare UPIN