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Organization
BRADDOCK MEDICAL GROUP P.A.
Active
Organization
BRADDOCK MEDICAL GROUP P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. PAUL TAYLOR LIVENGOOD (OWNER)
(301) 722-3111
Entity
Organization
Contact information
Practice address
912 SETON DR, CUMBERLAND, MD 21502-1818
(301) 722-3111
(301) 722-5135
Mailing address
912 SETON DR, CUMBERLAND, MD 21502-1818
(301) 722-3111
(301) 722-5135
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
—
—
261QP2300X
Primary Care Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0011509000
—
WV
05
—
00874296
—
PA
01
—
6216720003
CIGNA
—
05
—
910291400
—
MD
01
—
H529
MEDICARE GROUP ID
—
Enumeration date
05/31/2005
Last updated
03/21/2023
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