Healthcare Provider Details

I. General information

NPI: 1902910722
Provider Name (Legal Business Name): BLUEGRASS MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 CLINIC DR
PARIS KY
40361
US

IV. Provider business mailing address

22 CLINIC DR
PARIS KY
40361
US

V. Phone/Fax

Practice location:
  • Phone: 859-987-0074
  • Fax: 859-987-0098
Mailing address:
  • Phone: 859-987-0074
  • Fax: 859-987-0098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NATHAN L MOORE
Title or Position: PARTNER BLUEGRASS MEDICAL CLINIC PL
Credential: MD
Phone: 859-987-0074