| Organization Name: | BRADDOCK MEDICAL GROUP P.A. |
| NPI Number: | 1104962729 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | PAUL TAYLOR LIVENGOOD (OWNER) |
| Mailing Address: | 222 Lincoln Street Fort Ashby |
| State: | WV US |
| Postal Code: | 267191150 |
| Phone Number: | 3042983605 |
| Fax Number: | 3042983578 |
| NPI Enumeration Date: | 01/30/2007 |
| NPI Last Update Date: | 06/15/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 207QA0505X |
| License Number: | 11172 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WV |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Family Medicine |
| Taxonomy Specialization: | Adult Medicine |
| Taxonomy Definition: | |