Basic Information
Provider Information | |||||||||
NPI: | 1891009767 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BELLEFONTE PHYSICIAN SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BELLEFONTE FOOT CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2155 | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | KY | ||||||||
PostalCode: | 411052155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6068333333 | ||||||||
FaxNumber: | 6068334668 | ||||||||
Practice Location | |||||||||
Address1: | 1000 ASHLAND DR | ||||||||
Address2: | STE. 104 | ||||||||
City: | ASHLAND | ||||||||
State: | KY | ||||||||
PostalCode: | 411017084 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6068336260 | ||||||||
FaxNumber: | 6068336261 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/03/2010 | ||||||||
LastUpdateDate: | 05/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CONNETT | ||||||||
AuthorizedOfficialFirstName: | TROY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 6068333333 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 213E00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 000000674877 | 01 | KY | ANTHEM BCBS | OTHER | 3112143 | 05 | OH |   | MEDICAID | 7100131520 | 05 | KY |   | MEDICAID |