Healthcare Provider Details

I. General information

NPI: 1164518130
Provider Name (Legal Business Name): BLUEGRASS MEDICAL GROUP PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 HARRODSBURG RD SUITE D 502
LEXINGTON KY
40504-3758
US

IV. Provider business mailing address

1451 HARRODSBURG RD SUITE D 502
LEXINGTON KY
40504-3758
US

V. Phone/Fax

Practice location:
  • Phone: 859-277-8560
  • Fax: 859-277-8866
Mailing address:
  • Phone: 859-277-8560
  • Fax: 859-277-8866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25337
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number26673
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number3005655
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41917
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DANA RAE BARRY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 859-277-8560