Mountain State Medical Specialties, PLLC
Organization Active NPI Dermatology Physician · Bridgeport, WV
NPI 1891892097 · NPPES record last updated Mar 14, 2025
Key facts
- NPI
- 1891892097
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Dermatology Physician 207N00000X
- Legal business name
- MOUNTAIN STATE MEDICAL SPECIALTIES, PLLC
- Practice address
- 120 Medical Park Dr
Suite 200
Bridgeport, WV 26330-9012 - Phone
- (304) 624-7200
- Fax
- (304) 554-0413
- NPI assigned
- Sep 20, 2006
- Organization subpart
- No
Authorized official
- Name
- Eugene Brent Kirkland, MD
- Title
- Cmo
- Phone
- (513) 701-5526
Practitioners 46
-
David Charles Carlisle, M.D.
-
Megan Clatworthy, FNP
-
Destiny Brook Delapa, FNP-BC
-
Jeffrey A Dodson, M.D.
-
Sharifeh Farasat, MD
-
Charles Bradley Franz, M.D.
-
John G. Hancox, M.D.
-
Jeffrey Burke Jackson, M.D.
-
Janelle Marie King, M.D.
-
Todd Vincent Kreitzer, D.O.
-
Justin Blake Lee, MD
-
Heaven McGee, APRN
-
Amy B Norton, M.D.
-
Dominick Ryan Woofter, M.D.
-
Isha Woofter, M.D.
-
Alison Marian Spiker, M.D.
-
Randi Linn Dillon, PA-C
-
Kayla Annette Donoghue, PA-C
-
Alexander Ryan Epperly, PA-C
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (4 enrollments) in WV, PA, OH
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040308000599 | WV | Part B Supplier - Clinic/Group Practice | 9335046754 |
Receives reassigned benefits from 37 practitioners Practice locations: Bridgeport, WV; Clarksburg, WV; Elkins, WV; Huntington, WV; Hurricane, WV; Morgantown, WV; South Charleston, WV; Triadelphia, WV… |
| O20090306000306 | PA | Part B Supplier - Clinic/Group Practice | 9335046754 |
Receives reassigned benefits from 9 practitioners Practice locations: Uniontown, PA; Waynesburg, PA |
| O20120410000437 | WV | Part B Supplier - Independent Clinical Laboratory | 9335046754 | Practice locations: Bridgeport, WV |
| O20181126001990 | OH | Part B Supplier - Clinic/Group Practice | 9335046754 |
Receives reassigned benefits from 6 practitioners Practice locations: Marietta, OH |
National Provider Directory
Locations
1500 Ashwood Dr
Ste 1501
Canonsburg, PA 15317
Phone (304) 627-7200
204 Mary Higginson Ln
Uniontown, PA 15401
Phone (724) 438-0600
120 Medical Park Dr
Ste 200
Bridgeport, WV 26330
Phone (304) 624-7200
125 N 6th St
Clarksburg, WV 26301
Phone (304) 623-6533
700 W Pike St
Ste 200
Clarksburg, WV 26301
Phone (304) 624-6821
399 Emily Dr
Clarksburg, WV 26301
Phone (304) 624-4315
181 Middletown Cir
Fairmont, WV 26554
Phone (304) 367-9170
1840 Locust Ave
Fairmont, WV 26554
Phone (304) 366-6907
422 Kinetic Dr
Huntington, WV 25701
204 Chase Dr
Hurricane, WV 25526
Phone (304) 760-5144
165 Scott Ave
Ste 100
Morgantown, WV 26508
Phone (304) 554-0400
165 Scott Ave
Morgantown, WV 26508
Phone (304) 290-3329
165 Scott Ave
Ste 102
Morgantown, WV 26508
Phone (304) 554-0440
63 Wharf St
Morgantown, WV 26501
Phone (304) 291-3376
19 River Walk Mall
Ste 17
South Charleston, WV 25303
500 Cabela Dr
Triadelphia, WV 26059
Phone (618) 618-1011
800 Grand Central Mall
Ste 3
Vienna, WV 26105
Phone 30448548825
800 Grand Central Ave
Ste 3
Vienna, WV 26105
Phone (304) 865-0555
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Allergy & Immunology Physician |
207K00000X | |||
| Dermatology Physician |
207N00000X | Yes | ||
| MOHS-Micrographic Surgery Physician |
207ND0101X | |||
| Dermatopathology Physician |
207ND0900X | |||
| Procedural Dermatology Physician |
207NS0135X | |||
| Family Medicine Physician |
207Q00000X | |||
| Internal Medicine Physician |
207R00000X | |||
| Rheumatology Physician |
207RR0500X |
Addresses
Primary practice location
120 Medical Park Dr
Suite 200
Bridgeport, WV 26330-9012
Mailing address
PO Box 746750
Atlanta, GA 30374-6750
Phone (866) 680-8505
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3810004579 | Medicaid | WV |
Other providers in Bridgeport, WV
- Jordan Renee Morrison
- Saad Mossallati
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- Mountain Momma & Family Services, LLC
- Mountain River Physical Therapy, LLC
- Mountain State Medical Specialties,Inc.
- Mountainear Audiology & Hearing Aid Center, LLC
- Mountaineer Family Practice PLLC
- Mountaineer Medical Office Building Pharmacy
- Mountaineer Medical Pharmacy LLC
All providers in Bridgeport, WV · Dermatology Physician in West Virginia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 14, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.