Provider Demographics
NPI:1043387327
Name:BLUESTONE HEALTH ASSOCIATION, INC.
Entity Type:Organization
Organization Name:BLUESTONE HEALTH ASSOCIATION, INC.
Other - Org Name:PRUDICH MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:KISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-431-5499
Mailing Address - Street 1:5451 SIMMONS RIVER RD.
Mailing Address - Street 2:
Mailing Address - City:MONTCALM
Mailing Address - State:WV
Mailing Address - Zip Code:24737
Mailing Address - Country:US
Mailing Address - Phone:304-589-3251
Mailing Address - Fax:304-589-5363
Practice Address - Street 1:5451 SIMMONS RIVER ROAD
Practice Address - Street 2:
Practice Address - City:MONTCALM
Practice Address - State:WV
Practice Address - Zip Code:24737
Practice Address - Country:US
Practice Address - Phone:304-589-3251
Practice Address - Fax:304-589-5363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0035334000Medicaid
WVCD7656OtherRR MC
WV0022360001Medicaid
WV001706661OtherBCBS
WV511860Medicare Oscar/Certification