Healthcare Provider Details

I. General information

NPI: 1417499880
Provider Name (Legal Business Name): BLUEGRASS EAR, NOSE & THROAT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 HARRODSBURG RD SUITE 200
LEXINGTON KY
40503-2774
US

IV. Provider business mailing address

3080 HARRODSBURG RD SUITE 200
LEXINGTON KY
40503-2774
US

V. Phone/Fax

Practice location:
  • Phone: 859-277-3725
  • Fax: 859-276-6263
Mailing address:
  • Phone: 859-277-3725
  • Fax: 859-276-6263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number1037
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number26776
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number0546
License Number StateKY

VIII. Authorized Official

Name: ALBERT SPEACH
Title or Position: OWNER
Credential: M.D.
Phone: 859-277-3725