Provider Demographics
NPI:1386703718
Name:WESTERN MARYLAND HEALTH SYSTEM BRADDOCK HOSPITAL CORPORATION
Entity type:Organization
Organization Name:WESTERN MARYLAND HEALTH SYSTEM BRADDOCK HOSPITAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VP CFO
Authorized Official - Prefix:PROF
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:REPAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-723-1443
Mailing Address - Street 1:902 SETON DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-1873
Mailing Address - Country:US
Mailing Address - Phone:301-723-6365
Mailing Address - Fax:301-723-6277
Practice Address - Street 1:902 SETON DR
Practice Address - Street 2:SUITE 204
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1873
Practice Address - Country:US
Practice Address - Phone:301-723-6365
Practice Address - Fax:301-723-6277
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN MARYLAND HEALTH SYSTEM BRADDOCK HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-08
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001708660OtherMT. STATE BC BS
MD7741413-01Medicaid
MD774141304Medicaid
DCG362OtherFEDERAL BC BS
MDK936SEOtherBC BS MD
MD774141303Medicaid
MDCA5993 CH3960 CE790OtherTRAVELERS MEDICARE
DCG362OtherFEDERAL BC BS