Provider Demographics
NPI:1891892097
Name:MOUNTAIN STATE MEDICAL SPECIALTIES, PLLC
Entity type:Organization
Organization Name:MOUNTAIN STATE MEDICAL SPECIALTIES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:KIRKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-701-5526
Mailing Address - Street 1:PO BOX 746750
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6750
Mailing Address - Country:US
Mailing Address - Phone:866-680-8505
Mailing Address - Fax:937-436-4156
Practice Address - Street 1:120 MEDICAL PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9012
Practice Address - Country:US
Practice Address - Phone:304-624-7200
Practice Address - Fax:304-554-0413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207K00000X, 207ND0101X, 207ND0900X, 207NS0135X, 207Q00000X, 207R00000X, 207RR0500X, 207N00000X, 363A00000X, 363LF0000X
WV291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004579Medicaid
PA145432Medicare PIN
WV3810004579Medicaid