Basic Information
| Provider Information | |||||||||
| NPI: | 1043611015 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BELLEFONTE PHYSICIAN SERVICES, INC. | ||||||||
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| OtherOrganizationName: | BELLEFONTE PEDIATRICS, ASHLAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2155 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411052155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068334922 | ||||||||
| FaxNumber: | 6068334668 | ||||||||
| Practice Location | |||||||||
| Address1: | 2910 CARTER AVE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411011943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063269001 | ||||||||
| FaxNumber: | 6063269005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2014 | ||||||||
| LastUpdateDate: | 05/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | CONNETT | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6068333333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100317920 | 05 | KY | MEDICAID |