NPIMap

Individual provider Active NPI

Mark Leroy Gustafson, D.O.

  • Emergency Medicine Physician
  • Charleston, WV
National Provider Identifier
1851667000
Registry record updated Dec 16, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emergency Medicine PhysicianTaxonomy code 207P00000X
License
2723 Issued in WV
Practice address
3110 Maccorkle Ave SE
Charleston, WV 25304-1210
Phone
(304) 388-7170
NPI assigned
Mar 31, 2012
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 16, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine Physician 207P00000X 2723 WV Primary

Addresses

Primary practice location

3110 Maccorkle Ave SE
Charleston, WV 25304-1210

Mailing address

3100 Maccorkle Ave SE
Ste 203
Charleston, WV 25304-1228
Phone (304) 388-1724

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20140723000595 WV Practitioner - Emergency Medicine 8729204045 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Emergency Medicine
Education
Lincoln Memorial University Medical Department, 2012
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

3200 Maccorkle Ave SE
Charleston, WV 25304-1227
Phone (304) 388-5432

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
90.94 of 100Reported as apm
Quality
69.71
Promoting interoperability
100
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
2723WVMDGeneral Practice Dentistry

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 11

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1333152000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1481846400000",
    "number": "1851667000",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3100 MACCORKLE AVE SE",
            "address_2": "STE 203",
            "city": "CHARLESTON",
            "state": "WV",
            "postal_code": "253041228",
            "telephone_number": "304-388-1724",
            "fax_number": "304-388-1721"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3110 MACCORKLE AVE SE",
            "city": "CHARLESTON",
            "state": "WV",
            "postal_code": "253041210",
            "telephone_number": "304-388-7170"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GUSTAFSON",
        "first_name": "MARK",
        "middle_name": "LEROY",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-03-31",
        "last_updated": "2016-12-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "WV",
            "license": "2723",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Charleston, WV

Sources for this page

Verify at the official NPI Registry.