=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073799268
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEGRASS EYE SURGERY PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2008
-----------------------------------------------------
Last Update Date | 11/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 W WALNUT ST SUITE 400
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40033-1377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-692-0047
-----------------------------------------------------
Fax | 270-692-0219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 W WALNUT ST SUITE 400
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40033-1377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-692-0047
-----------------------------------------------------
Fax | 270-692-0219
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GARY N WORTZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 270-692-0047
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 40650
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------