Healthcare Provider Details

I. General information

NPI: 1942216775
Provider Name (Legal Business Name): RUSSEL BRICK MCKELWAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WEST MAIN STREET
BERRYVILLE VA
22611-1340
US

IV. Provider business mailing address

1 WEST MAIN STREET
BERRYVILLE VA
22611-1340
US

V. Phone/Fax

Practice location:
  • Phone: 540-667-1230
  • Fax: 540-277-2174
Mailing address:
  • Phone: 540-667-1230
  • Fax: 540-277-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101038662
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: