Healthcare Provider Details

I. General information

NPI: 1457555146
Provider Name (Legal Business Name): BLUEGRASS CLINIC LIBERTY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 N WALLACE WILKINSON BLVD
LIBERTY KY
42539-3014
US

IV. Provider business mailing address

256 N WALLACE WILKINSON BLVD
LIBERTY KY
42539-3014
US

V. Phone/Fax

Practice location:
  • Phone: 160-678-7001
  • Fax: 606-787-0035
Mailing address:
  • Phone: 606-787-0014
  • Fax: 606-787-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES A MILLER
Title or Position: PROVIDER OWNER
Credential: M.D.
Phone: 606-365-8338