Provider Demographics
NPI:1497707228
Name:BRADDOCK, EDWARD ROY (PT)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:ROY
Last Name:BRADDOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 LOUGHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVER FALLS
Mailing Address - State:PA
Mailing Address - Zip Code:15010-1422
Mailing Address - Country:US
Mailing Address - Phone:724-462-5650
Mailing Address - Fax:724-846-1867
Practice Address - Street 1:124 LOUGHRIDGE DR
Practice Address - Street 2:
Practice Address - City:BEAVER FALLS
Practice Address - State:PA
Practice Address - Zip Code:15010-1422
Practice Address - Country:US
Practice Address - Phone:724-846-5887
Practice Address - Fax:724-843-9276
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006762L225100000X
OHPT010934225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1627513OtherHIGHMARK BC/BS
OH000000359936OtherANTHEM BC/BS OF OHIO
P00272193OtherRAILROAD MEDICARE
OH2552830Medicaid
OHBR4147692Medicare ID - Type UnspecifiedINDIVIDUAL MDR FOR OHIO
PA1627513OtherHIGHMARK BC/BS
OH2552830Medicaid