1316946429 NPI number — BLUEGRASS MEDICAL ASSOCIATES PSC

Table of content: (NPI 1316946429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316946429 NPI number — BLUEGRASS MEDICAL ASSOCIATES PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEGRASS MEDICAL ASSOCIATES PSC
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:
Provider Other Organization Name Type Code:
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:
1316946429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 RIVER RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40206-1010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-814-3175
Provider Business Mailing Address Fax Number:
502-426-5493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 MALABU DR
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40502-3252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-223-2425
Provider Business Practice Location Address Fax Number:
859-224-8579
Provider Enumeration Date:
07/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GEORGE
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
859-223-2425

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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)

  • Identifier: 65933087 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: CI922 . This is a "RAILROAD MEDICARE KY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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