Healthcare Provider Details

I. General information

NPI: 1073814513
Provider Name (Legal Business Name): MOUNTAIN ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 DAVIS STURT ROAD
LEWISBURG WV
24901
US

IV. Provider business mailing address

PO BOX 631
LEWISBURG WV
24901-0631
US

V. Phone/Fax

Practice location:
  • Phone: 304-731-2313
  • Fax: 304-647-4570
Mailing address:
  • Phone: 304-731-2313
  • Fax: 304-647-4570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2245-8943
License Number StateWV

VIII. Authorized Official

Name: MR. BRADLEY PERSINGER
Title or Position: OWNER
Credential: CRNA
Phone: 304-542-3927