MEDICARE: BRADDOCK MEDICAL GROUP P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician	11172	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	850-290	OTHER		MAMSI MDIPA OPTIMUM
2	H529BR	OTHER	MD	BCBS GROUP #
3	W399	OTHER		BCBS FEDERAL PROVIDER #
4	00716943	OTHER	WV	BCBS PROVIDER #
5	41707101	OTHER	MD	BCBS PROVIDER #
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	0003	OTHER		BCBS FEDERAL GROUP #
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104962729
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRADDOCK MEDICAL GROUP P.A.

Provider Business Mailing Address
First Line	:	70 PRESIDENTS STREET
Second Line	:
City	:	FORT ASHBY
State	:	WV
Zip	:	26719-1150
Country	:	US
Telephone Number	:	304-298-3605
Fax Number	:	304-298-3578

Provider Business Practice Location Address
First Line	:	70 PRESIDENTS STREET
Second Line	:	UNIT 1150
City	:	FORT ASHBY
State	:	WV
Zip	:	26719-1150
Country	:	US
Telephone Number	:	304-298-3605
Fax Number	:	304-298-3578

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PAUL TAYLOR LIVENGOOD
Credential	:	MD
Telephone Number	:	304-298-3605

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	11/01/2016

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Directions to “BRADDOCK MEDICAL GROUP P.A. ” Practice Location

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