Healthcare Provider Details

I. General information

NPI: 1346356722
Provider Name (Legal Business Name): BELVEDERE MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BMC DERMATOLOGY ONG 850 WALNUT BOTTOM ROAD
CARLISLE PA
17013-3632
US

IV. Provider business mailing address

850 WALNUT BOTTOM ROAD BELVEDERE MEDICAL CORPORATION
CARLISLE PA
17013-3698
US

V. Phone/Fax

Practice location:
  • Phone: 717-245-0272
  • Fax: 717-243-2357
Mailing address:
  • Phone: 717-245-0272
  • Fax: 717-243-2357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier50000624
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCAP BLUE CROSS
# 2
Identifier0006561610001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
Identifier821504
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BLUE SHIELD

VIII. Authorized Official

Name: DR. GEORGE P BRANSCUM JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 717-243-1515