Provider Demographics
NPI:1750449526
Name:MELLEY, BRIAN CHRISTOPHER (DPM)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:CHRISTOPHER
Last Name:MELLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3012
Mailing Address - Country:US
Mailing Address - Phone:334-671-1441
Mailing Address - Fax:334-671-1688
Practice Address - Street 1:1550 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3012
Practice Address - Country:US
Practice Address - Phone:334-671-1441
Practice Address - Fax:334-671-1688
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003685L213E00000X
AL300213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA705422OtherBLUE SHIELD
PA0541161000OtherKEYSTONE
PA1292957Medicaid
480020003OtherRAILROAD MEDICARE
PAU26488Medicare UPIN
PA1292957Medicaid
480020003OtherRAILROAD MEDICARE
PA705422Medicare ID - Type Unspecified