Provider Demographics
NPI:1710053806
Name:MIDSTATE MEDICAL, INC
Entity Type:Organization
Organization Name:MIDSTATE MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HAL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCBEE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:410-643-3393
Mailing Address - Street 1:RR 4 BOX 40
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-9404
Mailing Address - Country:US
Mailing Address - Phone:304-788-2335
Mailing Address - Fax:
Practice Address - Street 1:167 S MINERAL ST
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2643
Practice Address - Country:US
Practice Address - Phone:304-788-2335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV009458332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD00419858100Medicaid
MH046928500OtherBLACK LUNG
TX010472101Medicaid
WI41669200Medicaid
WV0148368000Medicaid
MDZ157OtherCAREFIRST BCBS
PA0009717900004Medicaid
WI41669200Medicaid