Basic Information
| Provider Information | |||||||||
| NPI: | 1861499121 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELISLE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 CHAMBER CENTER DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593845248 | ||||||||
| Practice Location | |||||||||
| Address1: | 8780 US HIGHWAY 42 | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FLORENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410428850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593842660 | ||||||||
| FaxNumber: | 8593845248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 06/25/2014 | ||||||||
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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 | 207Q00000X | 34002859B | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 02651 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34.002859 | 01 | OH | MEDICAL LICENSE | OTHER | 64122195 | 05 | KY | MEDICAID | 02651 | 01 | KY | MEDICAL LICENSE | OTHER | 0426515 | 05 | OH | MEDICAID | P00344889 | 01 | KY | RAILROAD MEDICARE | OTHER |