Provider Demographics
NPI:1649292228
Name:MEDBROOK MEDICAL ASSOCIATES INC
Entity type:Organization
Organization Name:MEDBROOK MEDICAL ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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:26330-1492
Mailing Address - Country:US
Mailing Address - Phone:304-842-4233
Mailing Address - Fax:304-842-2574
Practice Address - Street 1:1370 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1492
Practice Address - Country:US
Practice Address - Phone:304-842-4233
Practice Address - Fax:304-842-2574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05522913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5012048OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WV6003063000Medicaid