Provider Demographics
NPI:1134196835
Name:POWDERLY, BRIAN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:POWDERLY
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 1:301 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2023-07-13
Deactivation Date:2021-07-26
Deactivation Code:
Reactivation Date:2023-07-13
Provider Licenses
StateLicense IDTaxonomies
WV14380207Q00000X
OH35076176P207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2125417Medicaid
000147520OtherMS BCBS
WV0057420000Medicaid
110019344OtherRR MEDICARE
WV0057420000Medicaid
WV9282251Medicare PIN
000147520OtherMS BCBS