Healthcare Provider Details

I. General information

NPI: 1912162959
Provider Name (Legal Business Name): BLUEGRASS RURAL HEALTH CLINIC, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2734 S HIGHWAY 421
MANCHESTER KY
40962-7515
US

IV. Provider business mailing address

151 N EAGLE CREEK DR STE 12
LEXINGTON KY
40509-1889
US

V. Phone/Fax

Practice location:
  • Phone: 606-658-2710
  • Fax: 606-658-2712
Mailing address:
  • Phone: 859-263-4341
  • Fax: 859-263-7441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33372
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number255P
License Number StateKY

VIII. Authorized Official

Name: KISHORE JADHAV
Title or Position: PRESIDENT
Credential: MD
Phone: 606-658-2710