Provider Demographics
NPI:1063481737
Name:BELLEVUE PROFESSIONAL SERVICES, INC.
Entity type:Organization
Organization Name:BELLEVUE PROFESSIONAL SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BUIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-483-4040
Mailing Address - Street 1:PO BOX 638775
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-8775
Mailing Address - Country:US
Mailing Address - Phone:800-514-4390
Mailing Address - Fax:440-808-3675
Practice Address - Street 1:1400 W MAIN ST
Practice Address - Street 2:BLDG 1, SUITE A
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811-9429
Practice Address - Country:US
Practice Address - Phone:419-483-2494
Practice Address - Fax:419-483-3224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35090068207Q00000X
OH34012014207Q00000X
OH34009034207V00000X
OH35127940207V00000X
OH34006462207X00000X
OH35068821207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2535377Medicaid
OH2535377Medicaid