Healthcare Provider Details

I. General information

NPI: 1821693656
Provider Name (Legal Business Name): MIRACLES OF LIFE OB/GYN, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
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 Number
License Number State

VIII. Authorized Official

Name: DR. RANDY M BRODNIK
Title or Position: OWNER
Credential: DO
Phone: 304-327-0531