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General NPI Number Information
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NPI Number | 1427478700
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Entity Type | Organization
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Legal Business Name | BLUEGRASS PEDIATRICS, LLC
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Dates
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Enumeration Date | 04/24/2014
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Last Update Date | 10/15/2024
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Provider Practice Location Address
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Address Line | 242 BERGER RD
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City | PADUCAH
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State | KY
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Zip | 42003
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Country | US
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Telephone | 270-366-0960
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Fax | 270-554-1108
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Provider Business Mailing Address
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Address Line | 242 BERGER RD
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City | PADUCAH
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State | KY
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Zip | 42003-4522
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Country | US
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Telephone | 270-366-0960
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Fax | 270-554-1108
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Authorized Official
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Title or Position | CREDENTIALING/BILLING MANAGER
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Name | TRUDY QUERTERMOUS
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Credential |
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Telephone | 270-366-0960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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