# MEDBROOK MEDICAL ASSOCIATES INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1013960632
- **Authorized official:** MR. TIM G BUGIN (VP PAYOR CONTRACTING)
- **Authorized official phone:** (304) 225-2500

## Contact information

- **Practice address:** 1370 JOHNSON AVENUE, BRIDGEPORT, WV 26330-1382
- **Practice address phone:** (304) 842-7186
- **Practice address fax:** (304) 842-9005
- **Mailing address:** PO BOX 719, DELLSLOW, WV 26531-0719
- **Mailing address phone:** (304) 842-7186
- **Mailing address fax:** (304) 842-9005

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 261QU0200X | Urgent Care Clinic/Center | — | NULL | — |

## Other

- **Enumeration date:** 05/17/2006
- **Last updated:** 02/14/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 0010647000 | — | WV |
| 01 | — | 0010647002 | MEDICAID LAB | WV |
| 01 | — | 01265 | STATE LICENSE | WV |
| 01 | — | 51D0925226 | CLIA | WV |