Provider Demographics
NPI:1831841675
Name:MOUNTAIN STATE ORTHOPEDICS AND SPORTS MEDICINE
Entity type:Organization
Organization Name:MOUNTAIN STATE ORTHOPEDICS AND 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:304-900-2589
Mailing Address - Street 1:4089 WEBSTER RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-7200
Mailing Address - Country:US
Mailing Address - Phone:304-900-2589
Mailing Address - Fax:
Practice Address - Street 1:4089W WEBSTER RD
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-9682
Practice Address - Country:US
Practice Address - Phone:304-900-2589
Practice Address - Fax:800-397-1586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty