Healthcare Provider Details

I. General information

NPI: 1609861996
Provider Name (Legal Business Name): RANDY M BRODNIK DO FACOG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 COURTHOUSE RD STE 202
PRINCETON WV
24740-2450
US

IV. Provider business mailing address

150 COURTHOUSE RD STE 202
PRINCETON WV
24740-2450
US

V. Phone/Fax

Practice location:
  • Phone: 304-327-0531
  • Fax: 304-324-0548
Mailing address:
  • Phone: 304-327-0531
  • Fax: 304-324-0548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number1566
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: