Provider Demographics
NPI:1457662579
Name:MOUNTAINEER SURGICAL ASSOCIATES PLLC
Entity Type:Organization
Organization Name:MOUNTAINEER SURGICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:WELDON
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-205-7912
Mailing Address - Street 1:PO BOX 11210
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-1210
Mailing Address - Country:US
Mailing Address - Phone:304-205-7912
Mailing Address - Fax:304-205-4694
Practice Address - Street 1:331 LAIDLEY ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1619
Practice Address - Country:US
Practice Address - Phone:304-205-7912
Practice Address - Fax:304-205-4694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22900208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1457662579OtherWELLS FARGO (PEIA)
233279270OtherOHIO BUREAU OF WORKERS' COMPENSATION
WV1104023795OtherCARELINK
615411900OtherDEPARTMENT OF LABOR
WV1457662579OtherUMWA HEALTH AND RETIREMENT FUNDS
WV233279270OtherMSBCBS
WV6336732OtherCIGNA
WVDQ8194OtherRAILROAD MEDICARE
WV1104023795Other4-MOST
WV1457662579OtherUNITED HEALTHCARE
WV3810018433Medicaid
WV3810018433Medicaid