Healthcare Provider Details

I. General information

NPI: 1831841675
Provider Name (Legal Business Name): MOUNTAIN STATE ORTHOPEDICS AND SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4089W WEBSTER RD
SUMMERSVILLE WV
26651-9682
US

IV. Provider business mailing address

4089 WEBSTER RD
SUMMERSVILLE WV
26651-7200
US

V. Phone/Fax

Practice location:
  • Phone: 304-900-2589
  • Fax: 800-397-1586
Mailing address:
  • Phone: 304-900-2589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. WILLIAM R CARSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 304-900-2589