Basic Information
| Provider Information | |||||||||
| NPI: | 1912200114 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELLEFONTE PHYSICIAN SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BELLEFONTE DIGESTIVE DISEASE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2155 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411052155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772144267 | ||||||||
| FaxNumber: | 6068334668 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 SAINT CHRISTOPHER DR STE 350 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068336350 | ||||||||
| FaxNumber: | 6068336352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2010 | ||||||||
| LastUpdateDate: | 05/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | CONNETT | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6068333333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | DN8303 | 01 | KY | RRMC | OTHER | 0000006921893 | 01 | KY | ANTHEM BCBS | OTHER |