Healthcare Provider Details

I. General information

NPI: 1972783157
Provider Name (Legal Business Name): BLUEGRASS FOOT AND ANKLE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 HIGHLAND PARK DR
RICHMOND KY
40475-3487
US

IV. Provider business mailing address

326 HIGHLAND PARK DR
RICHMOND KY
40475-3487
US

V. Phone/Fax

Practice location:
  • Phone: 859-623-3550
  • Fax:
Mailing address:
  • Phone: 859-623-3550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number00274
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number00274
License Number StateKY

VIII. Authorized Official

Name: DR. RANDALL W HALL
Title or Position: OWNER/DPM
Credential: DPM
Phone: 859-623-3550