1982755682 NPI number — BLUEGRASS SPINE CARE, PSC

Table of content: (NPI 1982755682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982755682 NPI number — BLUEGRASS SPINE CARE, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEGRASS SPINE CARE, 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:
1982755682
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1741 MIDLAND TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBYVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40065-1711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-633-0192
Provider Business Mailing Address Fax Number:
502-633-4164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1741 MIDLAND TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40065-1711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-633-0192
Provider Business Practice Location Address Fax Number:
502-633-4164
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MYERS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
502-633-0192

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X , with the licence number:  32619 , 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: 1063266 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000802487 . This is a "HUMANA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 122601 . This is a "CHA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2434349000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 5344332 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65930299 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5134693001 . This is a "CIGNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com