Basic Information
| Provider Information | |||||||||
| NPI: | 1508011131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BELLEFONTE PHYSICIAN SERVICES, INC. | ||||||||
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| OtherOrganizationName: | ASHLAND FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2155 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411052155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068334922 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2222 WINCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063259644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2008 | ||||||||
| LastUpdateDate: | 05/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | CONNETT | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6068333333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000578807 | 01 | KY | ANTHEM BCBS | OTHER | 7100049600 | 05 | KY | MEDICAID | 7100442070 | 05 | KY | MEDICAID |