NPIMap

Organization Active NPI

Mountain State Medical Specialties, PLLC

  • Dermatology Physician
  • Bridgeport, WV
National Provider Identifier
1891892097
Registry record updated Mar 14, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 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
Last updated
Mar 14, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 14, 2025

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

Authorized official

Name
Eugene Brent Kirkland, MD
Title
Cmo
Phone
(513) 701-5526

Specialties & licenses 8

Specialty (taxonomy)CodeLicenseStatePrimary
Allergy & Immunology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207K00000X
Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207N00000X Primary
MOHS-Micrographic Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207ND0101X
Dermatopathology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207ND0900X
Procedural Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207NS0135X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Rheumatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV, PA, OH4 enrollments

Enrollment records 4

Enrollment IDStateProvider typePAC IDDetails
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

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 101
Bridgeport, WV 26330
Phone (304) 624-7200

120 Medical Park Dr
Ste 200
Bridgeport, WV 26330
Phone (304) 624-7200

399 Emily Dr
Clarksburg, WV 26301
Phone (304) 624-4315

700 W Pike St
Ste 200
Clarksburg, WV 26301
Phone (304) 624-6821

1840 Locust Ave
Fairmont, WV 26554
Phone (304) 366-6907

422 Kinetic Dr
Huntington, WV 25701

422 Kinetic Dr
Ste B
Huntington, WV 25701
Phone (304) 523-5100

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
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 Ave
Ste 3
Vienna, WV 26105
Phone (304) 865-0555

800 Grand Central Mall
Ste 3
Vienna, WV 26105
Phone 30448548825

Practitioners & affiliated clinicians

Practitioners 47

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 47

NPI Registry JSON

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

{
    "created_epoch": "1158710400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1741910400000",
    "number": "1891892097",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 746750",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303746750",
            "telephone_number": "866-680-8505",
            "fax_number": "937-436-4156"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "120 MEDICAL PARK DR",
            "address_2": "SUITE 200",
            "city": "BRIDGEPORT",
            "state": "WV",
            "postal_code": "263309012",
            "telephone_number": "304-624-7200",
            "fax_number": "304-554-0413"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN STATE MEDICAL SPECIALTIES, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-20",
        "last_updated": "2025-03-14",
        "certification_date": "2025-03-14",
        "status": "A",
        "authorized_official_last_name": "KIRKLAND",
        "authorized_official_first_name": "EUGENE",
        "authorized_official_middle_name": "BRENT",
        "authorized_official_title_or_position": "CMO",
        "authorized_official_telephone_number": "513-701-5526",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207K00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Allergy & Immunology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207ND0900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, Dermatopathology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, Procedural Dermatology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RR0500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Rheumatology",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bridgeport, WV

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 14, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.