Basic Information
| Provider Information | |||||||||
| NPI: | 1316002199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELLVILLE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 LEXINGTON AVE | ||||||||
| Address2: | PO BOX 1595 | ||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2025 CARTER AVE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064084900 | ||||||||
| FaxNumber: | 6064082749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 12/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA227 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 002898 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 683 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 95000659 | 05 | KY | MEDICAID |