Provider Demographics
NPI:1962745950
Name:SWALM, JASON BRYCE (DO)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:BRYCE
Last Name:SWALM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 FOUNDATION WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-9000
Mailing Address - Country:US
Mailing Address - Phone:304-264-9202
Mailing Address - Fax:304-264-9042
Practice Address - Street 1:430 CERITOS TRL
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25403-0400
Practice Address - Country:US
Practice Address - Phone:304-267-6249
Practice Address - Fax:304-267-6248
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2952207P00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1962745950Medicaid
WV1962745950Medicaid