Healthcare Provider Details

I. General information

NPI: 1700868452
Provider Name (Legal Business Name): RUSSELL E. BELENCHIA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24345 HIGHWAY 15
UNION MS
39365-8575
US

IV. Provider business mailing address

PO BOX 2106
MERIDIAN MS
39302-2106
US

V. Phone/Fax

Practice location:
  • Phone: 601-774-8211
  • Fax: 601-774-8589
Mailing address:
  • Phone: 601-703-4282
  • Fax: 601-703-4597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10063
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number10063
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: