Provider Demographics
NPI:1225074438
Name:BRAUTIGAM, JOHN W (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:BRAUTIGAM
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2812
Mailing Address - Country:US
Mailing Address - Phone:304-599-2515
Mailing Address - Fax:304-285-3738
Practice Address - Street 1:943 MAPLE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2812
Practice Address - Country:US
Practice Address - Phone:304-599-2515
Practice Address - Fax:304-285-3738
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000852225100000X
PAPT002069E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0156774000Medicaid
WVBR0760451Medicare PIN