# BRADDOCK MEDICAL GROUP P.A.

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** BRADDOCK MEDICAL GROUP PA
- **Other names:** Fort Ashby Family Practice
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1104962729
- **Legal business name:** BRADDOCK MEDICAL GROUP PA
- **Authorized official:** DR. PAUL TAYLOR LIVENGOOD MD (OWNER)
- **Authorized official phone:** (304) 298-3605

## Contact information

- **Practice address:** 70 PRESIDENTS STREET, UNIT 1150, FORT ASHBY, WV 26719-1150
- **Practice address phone:** (304) 298-3605
- **Practice address fax:** (304) 298-3578
- **Mailing address:** 70 PRESIDENTS STREET, FORT ASHBY, WV 26719-1150
- **Mailing address phone:** (304) 298-3605
- **Mailing address fax:** (304) 298-3578

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207QA0505X | Adult Medicine Physician | 11172 | WV | Yes |

## Other

- **Enumeration date:** 01/30/2007
- **Last updated:** 11/01/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0003 | BCBS FEDERAL GROUP \# | — |
| 05 | — | 0056043000 | — | WV |
| 01 | — | 00716943 | BCBS PROVIDER \# | WV |
| 05 | — | 3810000010 | — | WV |
| 01 | — | 41707101 | BCBS PROVIDER \# | MD |
| 01 | — | 850-290 | MAMSI MDIPA OPTIMUM | — |
| 01 | — | H529BR | BCBS GROUP \# | MD |
| 01 | — | W399 | BCBS FEDERAL PROVIDER \# | — |