Healthcare Provider Details

I. General information

NPI: 1043387327
Provider Name (Legal Business Name): BLUESTONE HEALTH ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 05/12/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5451 SIMMONS RIVER ROAD
MONTCALM WV
24737
US

IV. Provider business mailing address

5451 SIMMONS RIVER RD.
MONTCALM WV
24737
US

V. Phone/Fax

Practice location:
  • Phone: 304-589-3251
  • Fax: 304-589-5363
Mailing address:
  • Phone: 304-589-3251
  • Fax: 304-589-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. REBECCA KISH
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 304-431-5499