Provider Demographics
NPI:1124003488
Name:BELLEFONTE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:BELLEFONTE MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:PRESTO
Authorized Official - Last Name:QUERUBIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:606-473-1501
Mailing Address - Street 1:PO BOX 828
Mailing Address - Street 2:
Mailing Address - City:GREENUP
Mailing Address - State:KY
Mailing Address - Zip Code:41144-1074
Mailing Address - Country:US
Mailing Address - Phone:606-473-1501
Mailing Address - Fax:606-473-1503
Practice Address - Street 1:401 US ROUTE 23
Practice Address - Street 2:
Practice Address - City:GREENUP
Practice Address - State:KY
Practice Address - Zip Code:41144-1074
Practice Address - Country:US
Practice Address - Phone:606-473-1501
Practice Address - Fax:606-473-1503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65939936Medicaid
DA4715OtherRR MEDICARE
000000235494OtherANTHEM BCBS
DA4715OtherRR MEDICARE