Basic Information
Provider Information | |||||||||
NPI: | 1689668535 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BELLO | ||||||||
FirstName: | BRODERICK | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7200 | ||||||||
Address2: |   | ||||||||
City: | ROCKY MOUNT | ||||||||
State: | NC | ||||||||
PostalCode: | 278040200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2529370200 | ||||||||
FaxNumber: | 2524510056 | ||||||||
Practice Location | |||||||||
Address1: | 102 S EASTPOINTE AVE | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 278561849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2524594012 | ||||||||
FaxNumber: | 2529373101 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2005 | ||||||||
LastUpdateDate: | 03/06/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 200100121 | NC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 89128VF | 05 | NC |   | MEDICAID | 4925344 | 01 | NC | CIGNA HEALTHCARE | OTHER | A5443 | 01 | NC | MEDCOST | OTHER | 128VF | 01 | NC | BCBSNC | OTHER | 2067731 | 01 | NC | UNITED HEALTH CARE | OTHER | 80170029 | 01 | NC | RAILROAD MEDICARE | OTHER |