=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164915633
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIMITRY BELOGORODSKY DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2018
-----------------------------------------------------
Last Update Date | 07/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2226 BLAKESLEE BOULEVARD DR E
-----------------------------------------------------
City | LEHIGHTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18235-9619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-297-3003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4577 BOONE ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128-4705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-531-0658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OT018631
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | OT018631
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | OS020327
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------