Healthcare Provider Details

I. General information

NPI: 1588402044
Provider Name (Legal Business Name): BLUEGRASS ID ASSOCIATED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 BABCOCK ST NE STE 303
PALM BAY FL
32905-4648
US

IV. Provider business mailing address

5200 BABCOCK ST NE STE 303
PALM BAY FL
32905-4648
US

V. Phone/Fax

Practice location:
  • Phone: 321-499-3077
  • Fax: 888-440-8238
Mailing address:
  • Phone: 321-499-3077
  • Fax: 888-440-8238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: ORIANA RAMIREZ
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 321-499-3077