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General NPI Number Information
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NPI Number | 1477646446
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Entity Type | Organization
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Legal Business Name | BEARGRASS MEDICAL ASSOCIATES PSC
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Dates
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Enumeration Date | 10/02/2006
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Last Update Date | 03/12/2010
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Provider Practice Location Address
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Address Line | 1169 EASTERN PKWY STE 1234
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City | LOUISVILLE
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State | KY
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Zip | 40217-1462
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Country | US
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Telephone | 502-456-3990
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Fax | 502-456-3988
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Provider Business Mailing Address
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Address Line | 1169 EASTERN PKWY STE 1234
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City | LOUISVILLE
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State | KY
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Zip | 40217-1462
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Country | US
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Telephone | 502-456-3990
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Fax | 502-456-3988
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Authorized Official
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Title or Position | PRESIDENT
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Name | HENRY JAMES WALTER
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Credential | MD
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Telephone | 502-456-3990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 17516
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 215554
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License Number State |
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