Provider Demographics
NPI:1104962729
Name:BRADDOCK MEDICAL GROUP P.A.
Entity type:Organization
Organization Name:BRADDOCK MEDICAL GROUP P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:LIVENGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-298-3605
Mailing Address - Street 1:70 PRESIDENTS STREET
Mailing Address - Street 2:
Mailing Address - City:FORT ASHBY
Mailing Address - State:WV
Mailing Address - Zip Code:26719-1150
Mailing Address - Country:US
Mailing Address - Phone:304-298-3605
Mailing Address - Fax:304-298-3578
Practice Address - Street 1:70 PRESIDENTS STREET
Practice Address - Street 2:UNIT 1150
Practice Address - City:FORT ASHBY
Practice Address - State:WV
Practice Address - Zip Code:26719-1150
Practice Address - Country:US
Practice Address - Phone:304-298-3605
Practice Address - Fax:304-298-3578
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRADDOCK MEDICAL GROUP PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-30
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11172207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
850-290OtherMAMSI MDIPA OPTIMUM
MDH529BROtherBCBS GROUP #
W399OtherBCBS FEDERAL PROVIDER #
WV00716943OtherBCBS PROVIDER #
MD41707101OtherBCBS PROVIDER #
WV3810000010Medicaid
0003OtherBCBS FEDERAL GROUP #
WV0056043000Medicaid
WV0056043000Medicaid
0003OtherBCBS FEDERAL GROUP #
WV0056043000Medicaid