Healthcare Provider Details

I. General information

NPI: 1265571020
Provider Name (Legal Business Name): BLUEGRASS CLINIC STANFORD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 METKER TRL SUITE A
STANFORD KY
40484-1049
US

IV. Provider business mailing address

107 METKER TRL SUITE A
STANFORD KY
40484-1049
US

V. Phone/Fax

Practice location:
  • Phone: 606-365-8338
  • Fax:
Mailing address:
  • Phone: 606-365-8338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number30199
License Number StateKY

VIII. Authorized Official

Name: DR. JAMES MILLER III
Title or Position: OWNER
Credential: M.D.
Phone: 606-365-8338