1619325719 NPI number — BLUEGRASS VASCULAR INSTITUTE

Table of content: (NPI 1619325719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619325719 NPI number — BLUEGRASS VASCULAR INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEGRASS VASCULAR INSTITUTE
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:
1619325719
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 FINANCIAL DR
Provider Second Line Business Mailing Address:
SUITE B103
Provider Business Mailing Address City Name:
ELIZABETHTOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-910-2377
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 FINANCIAL DR
Provider Second Line Business Practice Location Address:
SUITE B103
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-203-0300
Provider Business Practice Location Address Fax Number:
270-569-0000
Provider Enumeration Date:
05/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
AHMED
Authorized Official First Name:
MIRZA
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
404-775-3232

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  034761 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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