Bluestone Health Association, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Montcalm, WV
NPI 1043387327 · NPPES record last updated May 12, 2022
Key facts
- NPI
- 1043387327
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- BLUESTONE HEALTH ASSOCIATION, INC.
- Practice address
- 5451 Simmons River Road
Montcalm, WV 24737 - Phone
- (304) 589-3251
- Fax
- (304) 589-5363
- NPI assigned
- Nov 29, 2006
- Organization subpart
- No
Authorized official
- Name
- Mrs. Rebecca Kish
- Title
- Credentialing Specialist
- Phone
- (304) 431-5499
Other NPIs on the same Medicare enrollment 1
Other NPIs with the same Medicare PAC ID 6
Practitioners 43
-
Susan Fawn Blevins, FNP
-
Randy M Brodnik, DO FACOG
-
Leigh Brooks, APRN FNP-C
-
Heather Marie Cook, PA-C
-
Ashley Nicole Darago, FNP-BC
-
Jessica Ann Deel, NP-C
-
Bretina Hightower, BS, MSW, LGSW
-
Brandi Huffman, PA-C
-
Sabrina Kay Huffman, MSN, FNP
-
Brooke Alexandria Kirk, FNP-BC
-
Amy Lane, FNP-C
-
Miranda Lester, RN
-
Melissa D Lucado, FNP-C
-
Leah Renee Mooney, FNP-C
-
Nicholas Samuel Muscari, D.O.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in WV
Federally qualified health center certification: CCN 511860
- Legal name
- BLUESTONE HEALTH ASSOCIATION, INC.
- Doing business as
- PRUDICH MEDICAL CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Apr 16, 1997
- Last certification
- Apr 16, 1997
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Nov 26, 1976 in WV
- Enrollment address
- 5451 Simmons River Rd
Montcalm, WV 24737-0736
All disclosed owners & managing parties 8
| Name | Role | Since | Share |
|---|---|---|---|
| Norman Fletcher |
Corporate Officer |
Jan 1, 1995 | |
| Norma Clark |
Corporate Officer |
Jan 1, 2010 | |
| Pete Stamolis |
Corporate Officer |
Jan 1, 2001 | |
| Linda Hutchens |
Corporate Director |
Sep 1, 1993 | |
| W-2 Managing Employee |
Sep 1, 1993 | ||
| Marsha Howell |
Corporate Officer |
Jan 1, 1986 | |
| Mary Joann Dixon |
Corporate Officer |
Nov 30, 2020 | |
| Melanie Jessee |
Corporate Officer |
Oct 22, 2012 | |
| Susanne Pulse |
Corporate Officer |
Nov 30, 2020 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050831000052 | WV | Part a Provider - Federally Qualified Health Center (FQHC) | 3577505221 | Practice locations: Montcalm, WV |
| O20051115000502 | WV | Part B Supplier - Public Health/Welfare Agency | 3577505221 |
Receives reassigned benefits from 40 practitioners 1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Montcalm, WV; Princeton, WV |
National Provider Directory
Locations
701 Bland St
Bluefield, WV 24701
Phone (304) 800-5413
3997 Beckley Rd
Princeton, WV 24740
Phone (304) 431-5499
106 Thorn St
Princeton, WV 24740
Phone (304) 314-7501
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
5451 Simmons River Road
Montcalm, WV 24737
Mailing address
5451 Simmons River Rd.
Montcalm, WV 24737
Phone (304) 589-3251
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0035334000 | Medicaid | WV | |
| CD7656 | Other | WV | RR MC |
| 0022360001 | Medicaid | WV | |
| 001706661 | Other | WV | BCBS |
Other names
- Prudich Medical Center
Other providers in Montcalm, WV
All providers in Montcalm, WV · Federally Qualified Health Center (FQHC) in West Virginia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 12, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.