1104962729 NPI number — BRADDOCK MEDICAL GROUP P.A.

Table of content: (NPI 1104962729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104962729 NPI number — BRADDOCK MEDICAL GROUP P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADDOCK MEDICAL GROUP P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1104962729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 PRESIDENTS STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT ASHBY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26719-1150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-298-3605
Provider Business Mailing Address Fax Number:
304-298-3578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 PRESIDENTS STREET
Provider Second Line Business Practice Location Address:
UNIT 1150
Provider Business Practice Location Address City Name:
FORT ASHBY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26719-1150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-298-3605
Provider Business Practice Location Address Fax Number:
304-298-3578
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LIVENGOOD
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
TAYLOR
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-298-3605

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X , with the licence number:  11172 , 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)

  • Identifier: 850-290 . This is a "MAMSI MDIPA OPTIMUM" identifier . This identifiers is of the category "OTHER".
  • Identifier: H529BR . This is a "BCBS GROUP #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: W399 . This is a "BCBS FEDERAL PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00716943 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 41707101 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 3810000010 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0003 . This is a "BCBS FEDERAL GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0056043000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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