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General NPI Number Information
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NPI Number | 1104962729
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Entity Type | Organization
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Legal Business Name | BRADDOCK MEDICAL GROUP P.A.
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 11/01/2016
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Provider Practice Location Address
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Address Line | 70 PRESIDENTS STREET UNIT 1150
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City | FORT ASHBY
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State | WV
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Zip | 26719-1150
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Country | US
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Telephone | 304-298-3605
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Fax | 304-298-3578
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Provider Business Mailing Address
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Address Line | 70 PRESIDENTS STREET
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City | FORT ASHBY
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State | WV
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Zip | 26719-1150
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Country | US
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Telephone | 304-298-3605
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Fax | 304-298-3578
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Authorized Official
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Title or Position | OWNER
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Name | DR. PAUL TAYLOR LIVENGOOD
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Credential | MD
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Telephone | 304-298-3605
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 11172
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License Number State | WV
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