Provider Demographics
NPI:1982720801
Name:MOUNTAIN STATE MEDICINE AND RHEUMATOLOGY PLLC
Entity type:Organization
Organization Name:MOUNTAIN STATE MEDICINE AND RHEUMATOLOGY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOSHIA K
Authorized Official - Middle Name:PETRY
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:CMOM, CMC,CMPM, CMA
Authorized Official - Phone:304-400-4900
Mailing Address - Street 1:1120 KANAWHA BLVD E STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2400
Mailing Address - Country:US
Mailing Address - Phone:304-400-4900
Mailing Address - Fax:304-400-4907
Practice Address - Street 1:1120 KANAWHA BLVD E STE 200
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2400
Practice Address - Country:US
Practice Address - Phone:304-400-4900
Practice Address - Fax:304-400-4907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1818174400000X
WV1767174400000X
207R00000X, 207RR0500X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty