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General NPI Number Information
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NPI Number | 1104318625
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Entity Type | Organization
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Legal Business Name | MOUNTAIN STATE VASCULAR, INC.
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Dates
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Enumeration Date | 05/31/2018
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Last Update Date | 05/22/2024
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Provider Practice Location Address
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Address Line | 121 GEORGE STREET
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City | BECKLEY
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State | WV
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Zip | 25801
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Country | US
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Telephone | 304-250-0382
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1267
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City | LEWISBURG
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State | WV
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Zip | 24901-4267
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Country | US
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Telephone | 304-890-9910
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRIAN ROLAND WHYTE
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Credential | MD
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Telephone | 304-250-0382
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 22852
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License Number State | WV
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