Provider Demographics
NPI:1437493319
Name:MOUNTAIN STATE EYE ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:MOUNTAIN STATE EYE ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BOUNDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-353-0222
Mailing Address - Street 1:PO BOX 5308
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25361-0308
Mailing Address - Country:US
Mailing Address - Phone:304-353-0304
Mailing Address - Fax:304-353-0218
Practice Address - Street 1:1306 KANAWHA BLVD EAST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3001
Practice Address - Country:US
Practice Address - Phone:304-353-0304
Practice Address - Fax:304-353-0218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV8200D152W00000X
WVWV20725207W00000X
WVWV21067207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149311000Medicaid
WV3810005917Medicaid
WV2004585000Medicaid