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General NPI Number Information
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NPI Number | 1891892097
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Entity Type | Organization
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Legal Business Name | MOUNTAIN STATE MEDICAL SPECIALTIES, PLLC
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 03/14/2025
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Provider Practice Location Address
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Address Line | 120 MEDICAL PARK DR SUITE 200
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City | BRIDGEPORT
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State | WV
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Zip | 26330-9012
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Country | US
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Telephone | 304-624-7200
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Fax | 304-554-0413
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Provider Business Mailing Address
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Address Line | PO BOX 746750
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City | ATLANTA
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State | GA
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Zip | 30374-6750
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Country | US
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Telephone | 866-680-8505
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Fax | 937-436-4156
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Authorized Official
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Title or Position | CMO
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Name | EUGENE BRENT KIRKLAND
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Credential | MD
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Telephone | 513-701-5526
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207ND0900X
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Taxonomy Name | Dermatopathology Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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