Healthcare Provider Details

I. General information

NPI: 1922848381
Provider Name (Legal Business Name): MOUNTAINEER FAMILY MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4114 1ST AVE
NITRO WV
25143-1304
US

IV. Provider business mailing address

5240 MACCORKLE AVE SE
CHARLESTON WV
25304-2122
US

V. Phone/Fax

Practice location:
  • Phone: 304-755-0119
  • Fax:
Mailing address:
  • Phone: 681-264-4986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA WARNER
Title or Position: BILLING DIRECTOR
Credential:
Phone: 681-264-4986