Provider Demographics
NPI:1295862076
Name:WESTERN MARYLAND HEALTH SYSTEM BRADDOCK HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:WESTERN MARYLAND HEALTH SYSTEM BRADDOCK HOSPITAL CORPORATION
Other - Org Name:BHCENTRE LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:REPAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-723-6414
Mailing Address - Street 1:900 SETON DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-1854
Mailing Address - Country:US
Mailing Address - Phone:301-723-4200
Mailing Address - Fax:301-723-1480
Practice Address - Street 1:53 N CENTRE ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2305
Practice Address - Country:US
Practice Address - Phone:301-777-7071
Practice Address - Fax:301-723-1480
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN MARYLAND HEALTH SYSTEM BRADDOCK HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCH857 0001OtherFEDERAL BC BS
MD61636306OtherCAREFIRST BC BS
MD=========035OtherTRICARE