Provider Demographics
NPI:1326224353
Name:BELLEFONTE PHYSICIAN SERVICES, INC.
Entity Type:Organization
Organization Name:BELLEFONTE PHYSICIAN SERVICES, INC.
Other - Org Name:TRI-STATE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-833-3700
Mailing Address - Street 1:PO BOX 2155
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2155
Mailing Address - Country:US
Mailing Address - Phone:606-833-4922
Mailing Address - Fax:606-833-3450
Practice Address - Street 1:1000 ASHLAND DR STE 102
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101
Practice Address - Country:US
Practice Address - Phone:606-836-0919
Practice Address - Fax:606-836-2847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2877892Medicaid
KY000000550494OtherANTHEM BCBS
KY7100028510Medicaid
KY7100158620Medicaid