1497814768 NPI number — BLUEGRASS SURGICAL ASSOCIATION, PSC

Table of content: (NPI 1497814768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497814768 NPI number — BLUEGRASS SURGICAL ASSOCIATION, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEGRASS SURGICAL ASSOCIATION, 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:
1497814768
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
996 WILKINSON TRCE
Provider Second Line Business Mailing Address:
SUITE A5
Provider Business Mailing Address City Name:
BOWLING GREEN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42103-3407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-782-5219
Provider Business Mailing Address Fax Number:
270-793-9385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
996 WILKINSON TRCE
Provider Second Line Business Practice Location Address:
SUITE A5
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42103-3407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-782-5219
Provider Business Practice Location Address Fax Number:
270-793-9385
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KORBA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
270-782-5219

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  25747 , 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: 65924375 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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