Provider Demographics
NPI:1710980081
Name:BRADDOCK MEDICAL GROUP P.A.
Entity Type:Organization
Organization Name:BRADDOCK MEDICAL GROUP P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:LIVENGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-722-3111
Mailing Address - Street 1:912 SETON DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-1818
Mailing Address - Country:US
Mailing Address - Phone:301-722-3111
Mailing Address - Fax:301-722-5135
Practice Address - Street 1:912 SETON DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1818
Practice Address - Country:US
Practice Address - Phone:301-722-3111
Practice Address - Fax:301-722-5135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00874296Medicaid
MD910291400Medicaid
6216720003OtherCIGNA
H529OtherMEDICARE GROUP ID
WV0011509000Medicaid