Healthcare Provider Details

I. General information

NPI: 1720477672
Provider Name (Legal Business Name): BLUEGRASS PODIATRIC MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9800 SHELBYVILLE RD STE 202
LOUISVILLE KY
40223-5440
US

IV. Provider business mailing address

178 N EWING AVE
LOUISVILLE KY
40206-2459
US

V. Phone/Fax

Practice location:
  • Phone: 502-536-7224
  • Fax: 888-419-6943
Mailing address:
  • Phone: 502-554-3792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGIE LASORELLA
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 513-829-9333