Healthcare Provider Details

I. General information

NPI: 1427183219
Provider Name (Legal Business Name): MOUNTAIN STATE PLASTIC SURGEONS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4415 MACCORKLE AVE SE
CHARLESTON WV
25304-2505
US

IV. Provider business mailing address

4415 MACCORKLE AVE SE
CHARLESTON WV
25304-2505
US

V. Phone/Fax

Practice location:
  • Phone: 304-925-8949
  • Fax:
Mailing address:
  • Phone: 304-925-8949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number15926
License Number StateWV

VIII. Authorized Official

Name: DR. WILLIAM ANDREW STEWART
Title or Position: OWNER MEMBER
Credential: MD
Phone: 304-925-8949