Healthcare Provider Details

I. General information

NPI: 1073619128
Provider Name (Legal Business Name): BLUEGRASS NEWBORN SPECIALISTS, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 NORTH EAGLE CREEK DRIVE
LEXINGTON KY
40509-1805
US

IV. Provider business mailing address

1408 BRIANNA COURT
LEXINGTON KY
40513-1822
US

V. Phone/Fax

Practice location:
  • Phone: 859-967-5416
  • Fax: 859-967-5415
Mailing address:
  • Phone: 859-272-1146
  • Fax: 859-272-1146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number29168
License Number StateKY

VIII. Authorized Official

Name: DR. KHALDON JUNDI
Title or Position: OWNER
Credential: M.D.
Phone: 859-221-6339