Provider Demographics
NPI:1578692679
Name:MEDBROOK MEDICAL ASSOC. INC.
Entity Type:Organization
Organization Name:MEDBROOK MEDICAL ASSOC. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SALSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-842-7186
Mailing Address - Street 1:1370 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1382
Mailing Address - Country:US
Mailing Address - Phone:304-842-7186
Mailing Address - Fax:304-842-9005
Practice Address - Street 1:1370 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1382
Practice Address - Country:US
Practice Address - Phone:304-842-7186
Practice Address - Fax:304-842-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0010647002Medicaid