Provider Demographics
NPI:1285821561
Name:MOUNTAIN STATE ORTHOPEDICS & SPORTS MEDICINE
Entity Type:Organization
Organization Name:MOUNTAIN STATE ORTHOPEDICS & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-880-7988
Mailing Address - Street 1:PO BOX 927
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-0927
Mailing Address - Country:US
Mailing Address - Phone:304-880-7988
Mailing Address - Fax:304-880-7987
Practice Address - Street 1:400 FAIRVIEW HEIGHTS RD
Practice Address - Street 2:STE. 301
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-9308
Practice Address - Country:US
Practice Address - Phone:304-880-7988
Practice Address - Fax:304-880-7987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV18114204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0098219000Medicaid
WV200025785OtherRAILROAD MEDICARE
WV9286011OtherMEDICARE PROVIDER NUMBER
WV200025785OtherRAILROAD MEDICARE
WV9286011OtherMEDICARE PROVIDER NUMBER