# MOUNTAIN STATE VASCULAR, INC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104318625
- **Authorized official:** DR. BRIAN ROLAND WHYTE MD (OWNER)
- **Authorized official phone:** (304) 250-0382

## Contact information

- **Practice address:** 121 GEORGE STREET, BECKLEY, WV 25801
- **Practice address phone:** (304) 250-0382
- **Mailing address:** PO BOX 1267, LEWISBURG, WV 24901-4267
- **Mailing address phone:** (304) 890-9910

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2086S0129X | Vascular Surgery Physician | 22852 | WV | Yes |

## Other

- **Enumeration date:** 05/31/2018
- **Last updated:** 05/22/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1795 | WV BOARD OF MEDICINE REGISTRATION | WV |
| 01 | — | 9ALVR | STATE OF WV CERTIFICATE | WV |