=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801882303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT BRIAN WADE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2005
-----------------------------------------------------
Last Update Date | 04/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 3RD ST
-----------------------------------------------------
City | MOUNDSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26041-1606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-845-3464
-----------------------------------------------------
Fax | 304-845-2208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 WOOD DUCK MDW
-----------------------------------------------------
City | GLEN DALE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26038-1234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-845-3464
-----------------------------------------------------
Fax | 304-845-2208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 19185
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------