Provider Demographics
NPI:1588785471
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:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:REPAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-723-6414
Mailing Address - Street 1:300 E OLDTOWN RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-3600
Mailing Address - Country:US
Mailing Address - Phone:301-722-0199
Mailing Address - Fax:301-759-3623
Practice Address - Street 1:300 E OLDTOWN RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-3600
Practice Address - Country:US
Practice Address - Phone:301-722-0199
Practice Address - Fax:301-759-3623
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN MARYLAND HEALTH SYSTEM BRADDOCK HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-02
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDV613P3836OtherVETERAN'S ADMINISTRATION