Provider Demographics
NPI:1104592948
Name:SIDERS, BRIAN CAMERON
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:CAMERON
Last Name:SIDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1013
Mailing Address - Street 2:
Mailing Address - City:ELKVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:25071-1013
Mailing Address - Country:US
Mailing Address - Phone:304-881-8652
Mailing Address - Fax:
Practice Address - Street 1:2152 GREENBRIER ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-9622
Practice Address - Country:US
Practice Address - Phone:681-205-8108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV18788Medicaid