Healthcare Provider Details

I. General information

NPI: 1982720801
Provider Name (Legal Business Name): MOUNTAIN STATE MEDICINE AND RHEUMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 KANAWHA BLVD E STE 200
CHARLESTON WV
25301-2400
US

IV. Provider business mailing address

1120 KANAWHA BLVD E STE 200
CHARLESTON WV
25301-2400
US

V. Phone/Fax

Practice location:
  • Phone: 304-400-4900
  • Fax: 304-400-4907
Mailing address:
  • Phone: 304-400-4900
  • Fax: 304-400-4907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number1818
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number1767
License Number StateWV
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number StateNULL

VIII. Authorized Official

Name: DOSHIA K PETRY WARD
Title or Position: PRACTICE MANAGER
Credential: CMOM, CMC,CMPM, CMA
Phone: 304-400-4900