Healthcare Provider Details

I. General information

NPI: 1225048416
Provider Name (Legal Business Name): BLUEGRASS EAR NOSE & THROAT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 FLOYD CLAY DR SUITE 3
WINCHESTER KY
40391-1156
US

IV. Provider business mailing address

205 FLOYD CLAY DR SUITE 3
WINCHESTER KY
40391-1156
US

V. Phone/Fax

Practice location:
  • Phone: 859-745-1010
  • Fax: 859-745-0080
Mailing address:
  • Phone: 859-745-1010
  • Fax: 859-745-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateKY

VIII. Authorized Official

Name: ARA SAMUEL MAKDESSIAN
Title or Position: OWNER
Credential: MD
Phone: 859-745-1010