Healthcare Provider Details

I. General information

NPI: 1427478700
Provider Name (Legal Business Name): BLUEGRASS PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 10/15/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 BERGER RD
PADUCAH KY
42003
US

IV. Provider business mailing address

242 BERGER RD
PADUCAH KY
42003-4522
US

V. Phone/Fax

Practice location:
  • Phone: 270-366-0960
  • Fax: 270-554-1108
Mailing address:
  • Phone: 270-366-0960
  • Fax: 270-554-1108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TRUDY QUERTERMOUS
Title or Position: CREDENTIALING/BILLING MANAGER
Credential:
Phone: 270-366-0960