Healthcare Provider Details

I. General information

NPI: 1619973682
Provider Name (Legal Business Name): BLUEGRASS INTERNAL MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3346 PROFESSIONAL PARK DR
OWENSBORO KY
42303-4551
US

IV. Provider business mailing address

3346 PROFESSIONAL PARK
OWENSBORO KY
42303-4551
US

V. Phone/Fax

Practice location:
  • Phone: 270-685-1066
  • Fax: 270-685-0881
Mailing address:
  • Phone: 270-685-1066
  • Fax: 270-685-0881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANGELA LOUISE JARVIS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 270-685-1066