Provider Demographics
NPI:1811211048
Name:MOUNTAIN ROSE FAMILY MEDICINE INC
Entity Type:Organization
Organization Name:MOUNTAIN ROSE FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-597-2490
Mailing Address - Street 1:RT 4 BOX 104
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726
Mailing Address - Country:US
Mailing Address - Phone:304-597-2490
Mailing Address - Fax:304-597-2492
Practice Address - Street 1:ROUTE 4 BOX 104
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726
Practice Address - Country:US
Practice Address - Phone:304-597-2490
Practice Address - Fax:304-597-2492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV02095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I642323Medicare UPIN