MEDICARE: BRADDOCK MEDICAL GROUP P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor
2	261QP2300X	Primary Care Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	H529	OTHER		MEDICARE GROUP ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	6216720003	OTHER	CIGNA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710980081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRADDOCK MEDICAL GROUP P.A.

Provider Business Mailing Address
First Line	:	912 SETON DR
Second Line	:
City	:	CUMBERLAND
State	:	MD
Zip	:	21502-1818
Country	:	US
Telephone Number	:	301-722-3111
Fax Number	:	301-722-5135

Provider Business Practice Location Address
First Line	:	912 SETON DR
Second Line	:
City	:	CUMBERLAND
State	:	MD
Zip	:	21502-1818
Country	:	US
Telephone Number	:	301-722-3111
Fax Number	:	301-722-5135

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PAUL TAYLOR LIVENGOOD
Credential	:
Telephone Number	:	301-722-3111

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	03/21/2023

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Directions to “BRADDOCK MEDICAL GROUP P.A. ” Practice Location

Language	Start Address	Practice Location

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