Provider Demographics
NPI:1013960632
Name:MEDBROOK MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:MEDBROOK MEDICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP PAYOR CONTRACTING
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:G
Authorized Official - Last Name:BUGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-225-2500
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:DELLSLOW
Mailing Address - State:WV
Mailing Address - Zip Code:26531-0719
Mailing Address - Country:US
Mailing Address - Phone:304-842-7186
Mailing Address - Fax:304-842-9005
Practice Address - Street 1:1370 JOHNSON AVENUE
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:2006-05-17
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV01265OtherSTATE LICENSE
WV51D0925226OtherCLIA
WV0010647002OtherMEDICAID LAB
WV0010647000Medicaid
WV0010647000Medicaid
WV0010647002OtherMEDICAID LAB