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Organization
MEDBROOK MEDICAL ASSOCIATES INC
Active
Organization
MEDBROOK MEDICAL ASSOCIATES INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. TIM G BUGIN (VP PAYOR CONTRACTING)
(304) 225-2500
Entity
Organization
Contact information
Practice address
1370 JOHNSON AVENUE, BRIDGEPORT, WV 26330-1382
(304) 842-7186
(304) 842-9005
Mailing address
PO BOX 719, DELLSLOW, WV 26531-0719
(304) 842-7186
(304) 842-9005
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
NULL
207Q00000X
Family Medicine Physician
Primary
—
—
261QU0200X
Urgent Care Clinic/Center
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0010647000
—
WV
01
—
0010647002
MEDICAID LAB
WV
01
—
01265
STATE LICENSE
WV
01
—
51D0925226
CLIA
WV
Enumeration date
05/17/2006
Last updated
02/14/2012
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