Provider Demographics
NPI:1053329847
Name:BELIS, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:BELIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-2415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1414 9TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2415
Practice Address - Country:US
Practice Address - Phone:814-946-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026570E208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PW1015417OtherGATEWAY HEALTH PLAN
PA203181OtherUPMC HEALTH PLAN
PW10408OtherGEISINGER HEALTH PLAN
PA0009267120004Medicaid
PA033792Medicare ID - Type Unspecified
PW1015417OtherGATEWAY HEALTH PLAN