Basic Information
| Provider Information | |||||||||
| NPI: | 1346266848 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUESTONE HEALTH ASSOCIATION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLUESTONE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3997 BECKLEY RD | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247407660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044315499 | ||||||||
| FaxNumber: | 3044313400 | ||||||||
| Practice Location | |||||||||
| Address1: | 3997 BECKLEY RD | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247407660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044315499 | ||||||||
| FaxNumber: | 3044313400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | HUTCHENS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3044315499 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | CD7656 | 01 | WV | RR MC | OTHER | 001706661 | 01 | WV | BCBS | OTHER | 0035334000 | 05 | WV | MEDICAID | 001776052 | 01 | WV | BCBS | OTHER | 0022360001 | 05 | WV | MEDICAID |