Healthcare Provider Details

I. General information

NPI: 1639263338
Provider Name (Legal Business Name): BLUEGRASS PAIN MANAGEMENT, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 NICHOLASVILLE ROAD SUITE 503
LEXINGTON KY
40503
US

IV. Provider business mailing address

1760 NICHOLASVILLE ROAD SUITE 503
LEXINGTON KY
40503
US

V. Phone/Fax

Practice location:
  • Phone: 859-275-5229
  • Fax: 859-977-2683
Mailing address:
  • Phone: 859-275-5229
  • Fax: 859-977-2683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID P BOSOMWORTH II
Title or Position: OWNER
Credential: M.D.
Phone: 859-275-5229