MEDICARE: MOUNTAIN STATE ENT & FACIAL PLASTIC SURGERY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center	006769	WV

General Provider Information

NPI Number	:	1982604997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN STATE ENT & FACIAL PLASTIC SURGERY, INC

Provider Business Mailing Address
First Line	:	78 BROOKSHIRE LN
Second Line	:
City	:	BECKLEY
State	:	WV
Zip	:	25801-6765
Country	:	US
Telephone Number	:	304-255-2341
Fax Number	:	304-255-2343

Provider Business Practice Location Address
First Line	:	78 BROOKSHIRE LN
Second Line	:
City	:	BECKLEY
State	:	WV
Zip	:	25801-6765
Country	:	US
Telephone Number	:	304-255-2341
Fax Number	:	304-255-2343

Authorized Official
Title or Position	:	OWNER; PRESIDENT
Name	:	ALBERT JAMES PAINE JR.
Credential	:	MD
Telephone Number	:	304-255-2341

Provider Enumeration Date	:	08/01/2005
Last Update Date	:	03/29/2024

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