1003037375 NPI number — BLUEGRASS CARDIOLOGY PSC

Table of content: (NPI 1003037375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003037375 NPI number — BLUEGRASS CARDIOLOGY PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEGRASS CARDIOLOGY 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:
1003037375
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
793 EASTERN BYPASS
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 MERCY COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-624-1826
Provider Business Practice Location Address Fax Number:
859-624-1744
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MORRIS
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CORP PRESIDENT
Authorized Official Telephone Number:
859-624-1826

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  02196 , 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: 000000050520 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: CG1685 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65931958 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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