Provider Demographics
NPI:1104318625
Name:MOUNTAIN STATE VASCULAR, INC.
Entity type:Organization
Organization Name:MOUNTAIN STATE VASCULAR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ROLAND
Authorized Official - Last Name:WHYTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-250-0382
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-4267
Mailing Address - Country:US
Mailing Address - Phone:304-890-9910
Mailing Address - Fax:
Practice Address - Street 1:121 GEORGE STREET
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-250-0382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV228522086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1795OtherWV BOARD OF MEDICINE REGISTRATION
WV9ALVROtherSTATE OF WV CERTIFICATE