Basic Information
| Provider Information | |||||||||
| NPI: | 1912377813 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUESTONE HEALTH ASSOCIATION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHERN BLUESTONE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 12TH STREET EXT | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044315499 | ||||||||
| FaxNumber: | 3044313400 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 12TH STREET EXT | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044315499 | ||||||||
| FaxNumber: | 3044313400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2015 | ||||||||
| LastUpdateDate: | 12/15/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | HUTCHENS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3044315499 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BLUESTONE HEALTH ASSOCIATION, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.