Healthcare Provider Details

I. General information

NPI: 1104962729
Provider Name (Legal Business Name): BRADDOCK MEDICAL GROUP P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 PRESIDENTS STREET UNIT 1150
FORT ASHBY WV
26719-1150
US

IV. Provider business mailing address

70 PRESIDENTS STREET
FORT ASHBY WV
26719-1150
US

V. Phone/Fax

Practice location:
  • Phone: 304-298-3605
  • Fax: 304-298-3578
Mailing address:
  • Phone: 304-298-3605
  • Fax: 304-298-3578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number11172
License Number StateWV

VIII. Authorized Official

Name: DR. PAUL TAYLOR LIVENGOOD
Title or Position: OWNER
Credential: MD
Phone: 304-298-3605