=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316946429
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEGRASS MEDICAL ASSOCIATES PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 MALABU DR SUITE 212
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40502-3252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-223-2425
-----------------------------------------------------
Fax | 859-224-8579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2301 RIVER RD SUITE 300
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40206-1010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-814-3175
-----------------------------------------------------
Fax | 502-426-5493
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | MR. JAMES GEORGE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 859-223-2425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------