Healthcare Provider Details

I. General information

NPI: 1245819390
Provider Name (Legal Business Name): MOUNTAINEER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NEW HOPE ROAD
PRINCETON WV
24740
US

IV. Provider business mailing address

310 GEORGE ST
BECKLEY WV
25801-2653
US

V. Phone/Fax

Practice location:
  • Phone: 304-207-6531
  • Fax:
Mailing address:
  • Phone: 681-207-3652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER M MILLER
Title or Position: ADMINISTRATOR
Credential:
Phone: 681-207-3653