Healthcare Provider Details

I. General information

NPI: 1285821561
Provider Name (Legal Business Name): MOUNTAIN STATE ORTHOPEDICS & SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 12/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FAIRVIEW HEIGHTS RD STE. 301
SUMMERSVILLE WV
26651-9308
US

IV. Provider business mailing address

PO BOX 927
SUMMERSVILLE WV
26651-0927
US

V. Phone/Fax

Practice location:
  • Phone: 304-880-7988
  • Fax: 304-880-7987
Mailing address:
  • Phone: 304-880-7988
  • Fax: 304-880-7987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberWV18114
License Number StateWV

VIII. Authorized Official

Name: DR. WILLIAM R. CARSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 304-880-7988