Provider Demographics
NPI:1376604868
Name:BELEZOS MEDICAL PC
Entity Type:Organization
Organization Name:BELEZOS MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:V
Authorized Official - Last Name:BELEZOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-765-4900
Mailing Address - Street 1:100 SOUTH ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-4051
Mailing Address - Country:US
Mailing Address - Phone:508-765-4900
Mailing Address - Fax:508-765-4908
Practice Address - Street 1:100 SOUTH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4051
Practice Address - Country:US
Practice Address - Phone:508-765-4900
Practice Address - Fax:508-765-4908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78702207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9760211Medicaid
MAM19245OtherBLUE CROSS
MA651260OtherTUFTS
MA116881OtherFALLON