1083668875 NPI number — MOUNTAIN STATE PHYSICAL THERAPY LLC

Table of content: (NPI 1083668875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083668875 NPI number — MOUNTAIN STATE PHYSICAL THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN STATE PHYSICAL THERAPY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083668875
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 FAIRMONT AVE STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26554-0171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-363-8543
Provider Business Mailing Address Fax Number:
304-363-0173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 FAIRMONT AVE STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26554-0171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-363-8543
Provider Business Practice Location Address Fax Number:
304-363-0173
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BARRISH
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
304-363-8543

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0202606000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: DB3679 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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