=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720477672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEGRASS PODIATRIC MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2015
-----------------------------------------------------
Last Update Date | 10/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9800 SHELBYVILLE RD STE 202
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40223-5440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-536-7224
-----------------------------------------------------
Fax | 888-419-6943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 178 N EWING AVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40206-2459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-554-3792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SUPERVISOR
-----------------------------------------------------
Name | ANGIE LASORELLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-829-9333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------