Healthcare Provider Details

I. General information

NPI: 1902072291
Provider Name (Legal Business Name): BLUEGRASS BARIATRIC SURGICAL ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 10/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 OLD ROSEBUD RD SUITE 350
LEXINGTON KY
40509-8559
US

IV. Provider business mailing address

2716 OLD ROSEBUD RD SUITE 350
LEXINGTON KY
40509-8559
US

V. Phone/Fax

Practice location:
  • Phone: 859-543-1577
  • Fax: 859-543-1637
Mailing address:
  • Phone: 859-543-1577
  • Fax: 859-543-1637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35422
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number42220
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number30697
License Number StateKY

VIII. Authorized Official

Name: MR. DEAN M OSCHWALD
Title or Position: CEO
Credential:
Phone: 859-543-1577