Provider Demographics
NPI:1477669851
Name:BELVEDERE MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BELVEDERE MEDICAL CORPORATION
Other - Org Name:BMC DERMATOLOGY KOLEV
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRANSCUM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:717-243-1515
Mailing Address - Street 1:850 WALNUT BOTTOM ROAD
Mailing Address - Street 2:BMC DERM KOLEV
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-3632
Mailing Address - Country:US
Mailing Address - Phone:717-218-3505
Mailing Address - Fax:717-243-0046
Practice Address - Street 1:850 WALNUT BOTTOM ROAD
Practice Address - Street 2:BMC DERM KOLEV
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013-3632
Practice Address - Country:US
Practice Address - Phone:717-218-3505
Practice Address - Fax:717-243-0046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006561610001Medicaid
PA50000717OtherCAP BLUE CROSS
PA1407025OtherHIGHMARK BLUE SHIELD
PA1407025OtherHIGHMARK BLUE SHIELD