Provider Demographics
NPI:1700868452
Name:BELENCHIA, RUSSELL E (DO)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:E
Last Name:BELENCHIA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2106
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2106
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:24345 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MS
Practice Address - Zip Code:39365-8575
Practice Address - Country:US
Practice Address - Phone:601-774-8211
Practice Address - Fax:601-774-8589
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10063207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115507Medicaid
080168657OtherRAILROAD MEDICARE
MS080003423Medicare PIN
080168657OtherRAILROAD MEDICARE