Organization
BRADDOCK MEDICAL GROUP P.A.
Active
Parent organization
BRADDOCK MEDICAL GROUP PA
Other names
Fort Ashby Family Practice
Organization subpart
Yes
Provider details
NPI number
Legal business name
BRADDOCK MEDICAL GROUP PA
Authorized official
DR. PAUL TAYLOR LIVENGOOD MD (OWNER)
(304) 298-3605
Entity
Organization
Contact information
Practice address
70 PRESIDENTS STREET, UNIT 1150, FORT ASHBY, WV 26719-1150
(304) 298-3605
(304) 298-3578
Mailing address
70 PRESIDENTS STREET, FORT ASHBY, WV 26719-1150
(304) 298-3605
(304) 298-3578
Taxonomy
Speciality
Code
Description
License number
State
207QA0505X
Adult Medicine Physician
Primary
11172
WV
Other
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 #
—
Enumeration date
01/30/2007
Last updated
11/01/2016
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