Basic Information
| Provider Information | |||||||||
| NPI: | 1013919968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELMONT | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 12TH ST N STE 202 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202583090 | ||||||||
| FaxNumber: | 7152583095 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 12TH ST N STE 202 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202583090 | ||||||||
| FaxNumber: | 3202583095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 41952 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 30096100 | 05 | WI | MEDICAID |