1104318625 NPI number — MOUNTAIN STATE VASCULAR, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104318625 NPI number — MOUNTAIN STATE VASCULAR, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN STATE VASCULAR, INC.
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:
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:
1104318625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1267
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24901-4267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-890-9910
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 GEORGE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BECKLEY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-250-0382
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2018

Additional Information

Authorized Official

Authorized Official Last Name:
WHYTE
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
ROLAND
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-250-0382

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  22852 , 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: 1795 . This is a "WV BOARD OF MEDICINE REGISTRATION" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 9ALVR . This is a "STATE OF WV CERTIFICATE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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