Healthcare Provider Details

I. General information

NPI: 1659347540
Provider Name (Legal Business Name): MOUNTAINSTATE ORTHOPEDIC ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ORTHOPEDIC WAY
MORGANTOWN WV
26505-1240
US

IV. Provider business mailing address

200 ORTHOPEDIC WAY
MORGANTOWN WV
26505-1240
US

V. Phone/Fax

Practice location:
  • Phone: 304-599-0720
  • Fax: 304-599-3962
Mailing address:
  • Phone: 304-599-0720
  • Fax: 304-599-3962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: TRACEY L SNEED
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 304-599-0720