Basic Information
| Provider Information | |||||||||
| NPI: | 1295862076 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN MARYLAND HEALTH SYSTEM BRADDOCK HOSPITAL CORPORATION | ||||||||
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| OtherOrganizationName: | BHCENTRE LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 SETON DR | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215021854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017234200 | ||||||||
| FaxNumber: | 3017231480 | ||||||||
| Practice Location | |||||||||
| Address1: | 53 N CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215022305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017777071 | ||||||||
| FaxNumber: | 3017231480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | REPAC | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP CFO | ||||||||
| AuthorizedOfficialTelephone: | 3017236414 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WESTERN MARYLAND HEALTH SYSTEM BRADDOCK HOSPITAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | H857 0001 | 01 | DC | FEDERAL BC BS | OTHER | 61636306 | 01 | MD | CAREFIRST BC BS | OTHER |