Provider Demographics
NPI:1447349238
Name:MOUNTAIN STATE MEDICAL ASSOCIATES PLLC
Entity type:Organization
Organization Name:MOUNTAIN STATE MEDICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-346-5533
Mailing Address - Street 1:300 KENTON DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1263
Mailing Address - Country:US
Mailing Address - Phone:304-346-5533
Mailing Address - Fax:304-346-5611
Practice Address - Street 1:300 KENTON DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1263
Practice Address - Country:US
Practice Address - Phone:304-346-5533
Practice Address - Fax:304-346-5611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20410207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00189318OtherUMWA PIN NUMBER FOR THE GROUP
WVDC7713OtherUMWA NUMBER FOR THE GROUP
WVP00215125OtherRAILROAD NUMBER FOR THE GROUP
WV001706175OtherBLUE CROSS NUMBER FOR THE GROUP
WV1447349238OtherNPI NUMBER FOR THE GROUP
WV3810001081Medicaid
WVP00189318OtherUMWA PIN NUMBER FOR THE GROUP
WVM09348961Medicare PIN