Healthcare Provider Details

I. General information

NPI: 1174615587
Provider Name (Legal Business Name): BRIAN RIEDEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR POC PEDIATRIC CLINIC
MORGANTOWN WV
26506
US

IV. Provider business mailing address

1 MEDICAL CENTER DR PO BOX 9214
MORGANTOWN WV
26506-9214
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-1017
  • Fax: 304-293-4337
Mailing address:
  • Phone: 304-293-1017
  • Fax: 304-293-4337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number23973
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: