Healthcare Provider Details

I. General information

NPI: 1336632660
Provider Name (Legal Business Name): MOUNTAINEER CARDIOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 CHESTERFIELD AVE STE 302
CHARLESTON WV
25304-1064
US

IV. Provider business mailing address

2345 CHESTERFIELD AVE STE 302
CHARLESTON WV
25304-1064
US

V. Phone/Fax

Practice location:
  • Phone: 681-205-8610
  • Fax: 681-205-8615
Mailing address:
  • Phone: 681-205-8610
  • Fax: 681-205-8615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN L. GOAD
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 681-205-8610