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General NPI Number Information
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NPI Number | 1497814768
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Entity Type | Organization
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Legal Business Name | BLUEGRASS SURGICAL ASSOCIATION, PSC
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 12/14/2010
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Provider Practice Location Address
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Address Line | 996 WILKINSON TRCE SUITE A5
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City | BOWLING GREEN
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State | KY
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Zip | 42103-3407
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Country | US
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Telephone | 270-782-5219
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Fax | 270-793-9385
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Provider Business Mailing Address
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Address Line | 996 WILKINSON TRCE SUITE A5
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City | BOWLING GREEN
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State | KY
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Zip | 42103-3407
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Country | US
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Telephone | 270-782-5219
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Fax | 270-793-9385
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOHN L KORBA
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Credential | MD
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Telephone | 270-782-5219
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 25747
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License Number State | KY
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