Provider Demographics
NPI:1558405266
Name:WESTERN MARYLAND HEALTH SYSTEM BRADDOCK HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:WESTERN MARYLAND HEALTH SYSTEM BRADDOCK HOSPITAL CORPORATION
Other - Org Name:WMHS BRADDOCK HOSPITAL DIAGNOSTIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:REPAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-964-8342
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:240-964-8342
Mailing Address - Fax:240-964-8337
Practice Address - Street 1:900 SETON DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1854
Practice Address - Country:US
Practice Address - Phone:240-964-8342
Practice Address - Fax:240-964-8337
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN MARYLAND HEALTH BRADDOCK HOSPITAL CORPORTATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-16
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD261QR0200X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD61636306OtherCAREFIRST CENTRE ST LAB
MDW474SAOtherFHC CAREFIRST GRP.
MD61636304OtherCAREFIRST FHC LAB
MD62018801 KFA5SAOtherCAREFIRST FHC X-RAY
DCH857 0001OtherBLUE CHOICE LABORATORY
DCH856 0001OtherBLUE CHOICE X-RAY FHC
DCH856 0001OtherBLUE CHOICE X-RAY FHC