Basic Information
| Provider Information | |||||||||
| NPI: | 1083823421 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUR LADY OF BELLEFONTE HOSPITAL | ||||||||
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| OtherOrganizationName: | BELLEFONTE HEART CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1180 SAINT CHRISTOPHER DR | ||||||||
| Address2: | STE. 2 | ||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068330144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1180 SAINT CHRISTOPHER DR | ||||||||
| Address2: | STE. 2 | ||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068330144 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 09/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | BUCCHEIT | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6068333333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 2793946 | 05 | OH | MEDICAID | 000000551196 | 01 | KY | ANTHEM BCBS | OTHER | 7100011690 | 05 | KY | MEDICAID |