Healthcare Provider Details

I. General information

NPI: 1982755682
Provider Name (Legal Business Name): BLUEGRASS SPINE CARE, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1741 MIDLAND TRL
SHELBYVILLE KY
40065-1711
US

IV. Provider business mailing address

1741 MIDLAND TRL
SHELBYVILLE KY
40065-1711
US

V. Phone/Fax

Practice location:
  • Phone: 502-633-0192
  • Fax: 502-633-4164
Mailing address:
  • Phone: 502-633-0192
  • Fax: 502-633-4164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number32619
License Number StateKY

VIII. Authorized Official

Name: MARK A MYERS
Title or Position: OWNER
Credential: MD
Phone: 502-633-0192