1972805802 NPI number — MR. BRADFORD CLINTON BUDDENBERG CRNA

Table of content: MR. BRADFORD CLINTON BUDDENBERG CRNA (NPI 1972805802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972805802 NPI number — MR. BRADFORD CLINTON BUDDENBERG CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUDDENBERG
Provider First Name:
BRADFORD
Provider Middle Name:
CLINTON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972805802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 HAYES ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26501-6812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-228-5040
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2215 SMITH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25314-2110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-346-7313
Provider Business Practice Location Address Fax Number:
304-744-9802
Provider Enumeration Date:
11/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  66365 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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