1477092260 NPI number — BLUEGRASS OUTPATIENT CENTER OF BOWLING GREEN, LLC

Table of content: (NPI 1477092260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477092260 NPI number — BLUEGRASS OUTPATIENT CENTER OF BOWLING GREEN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEGRASS OUTPATIENT CENTER OF BOWLING GREEN, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BLUEGRASS OUTPATIENT CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477092260
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 896114
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28289-6114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-586-8947
Provider Business Mailing Address Fax Number:
270-713-0234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1020 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42134-2370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-586-8947
Provider Business Practice Location Address Fax Number:
270-713-0234
Provider Enumeration Date:
02/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SOWELL
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
G
Authorized Official Title or Position:
EXEC. VICE PRESIDENT
Authorized Official Telephone Number:
270-745-1500

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X , with the licence number:  100615 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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