Healthcare Provider Details

I. General information

NPI: 1982604997
Provider Name (Legal Business Name): MOUNTAIN STATE ENT & FACIAL PLASTIC SURGERY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 BROOKSHIRE LN
BECKLEY WV
25801-6765
US

IV. Provider business mailing address

78 BROOKSHIRE LN
BECKLEY WV
25801-6765
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-2341
  • Fax: 304-255-2343
Mailing address:
  • Phone: 304-255-2341
  • Fax: 304-255-2343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number006769
License Number StateWV

VIII. Authorized Official

Name: ALBERT JAMES PAINE JR.
Title or Position: OWNER; PRESIDENT
Credential: MD
Phone: 304-255-2341