Provider Demographics
NPI:1326546151
Name:BELLGRADE MEDICAL
Entity Type:Organization
Organization Name:BELLGRADE MEDICAL
Other - Org Name:BELLGRADE MEDICAL, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-598-4799
Mailing Address - Street 1:2621 PROMENADE PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-4905
Mailing Address - Country:US
Mailing Address - Phone:804-897-3746
Mailing Address - Fax:
Practice Address - Street 1:2621 PROMENADE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-4905
Practice Address - Country:US
Practice Address - Phone:804-897-3746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-26
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102032395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0102032395OtherSTATE LICENSE