Provider Demographics
NPI:1861499121
Name:BELISLE, ROBERT J (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:BELISLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 CHAMBER CENTER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1673
Mailing Address - Country:US
Mailing Address - Phone:859-344-5555
Mailing Address - Fax:859-384-5248
Practice Address - Street 1:8780 US HIGHWAY 42
Practice Address - Street 2:SUITE A
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-8850
Practice Address - Country:US
Practice Address - Phone:859-384-2660
Practice Address - Fax:859-384-5248
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002859B207Q00000X
KY02651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34.002859OtherMEDICAL LICENSE
KY64122195Medicaid
KY02651OtherMEDICAL LICENSE
OH0426515Medicaid
KYP00344889OtherRAILROAD MEDICARE
KY008580037Medicare PIN
OH0426515Medicaid
KYP00344889OtherRAILROAD MEDICARE