Provider Demographics
NPI:1215515408
Name:BRIGHTWELL HEALTH LLC
Entity type:Organization
Organization Name:BRIGHTWELL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DREW
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-622-4317
Mailing Address - Street 1:7310 RITCHIE HWY STE 516
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3099
Mailing Address - Country:US
Mailing Address - Phone:844-387-7469
Mailing Address - Fax:844-708-1264
Practice Address - Street 1:7310 RITCHIE HWY STE 516
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3099
Practice Address - Country:US
Practice Address - Phone:443-221-2222
Practice Address - Fax:844-708-1264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0053298OtherLICENSE