Healthcare Provider Details

I. General information

NPI: 1013960632
Provider Name (Legal Business Name): MEDBROOK MEDICAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 JOHNSON AVENUE
BRIDGEPORT WV
26330-1382
US

IV. Provider business mailing address

PO BOX 719
DELLSLOW WV
26531-0719
US

V. Phone/Fax

Practice location:
  • Phone: 304-842-7186
  • Fax: 304-842-9005
Mailing address:
  • Phone: 304-842-7186
  • Fax: 304-842-9005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TIM G BUGIN
Title or Position: VP PAYOR CONTRACTING
Credential:
Phone: 304-225-2500