1063481737 NPI number — BELLEVUE PROFESSIONAL SERVICES, INC.

Table of content: (NPI 1063481737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063481737 NPI number — BELLEVUE PROFESSIONAL SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELLEVUE PROFESSIONAL SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GREAT LAKES PHYSICIANS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063481737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 638775
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-8775
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-514-4390
Provider Business Mailing Address Fax Number:
440-808-3675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 W MAIN ST
Provider Second Line Business Practice Location Address:
BLDG 1, SUITE A
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44811-9429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-483-2494
Provider Business Practice Location Address Fax Number:
419-483-3224
Provider Enumeration Date:
03/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUIT
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
419-483-4040

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  35090068 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 34012014 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 35068821 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: 34009034 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 35127940 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 34006462 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2535377 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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