MEDICARE: BEARGRASS MEDICAL ASSOCIATES PSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	17516
2	207R00000X	Internal Medicine Physician	215554

General Provider Information

NPI Number	:	1477646446
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEARGRASS MEDICAL ASSOCIATES PSC

Provider Business Mailing Address
First Line	:	1169 EASTERN PKWY
Second Line	:	STE 1234
City	:	LOUISVILLE
State	:	KY
Zip	:	40217-1462
Country	:	US
Telephone Number	:	502-456-3990
Fax Number	:	502-456-3988

Provider Business Practice Location Address
First Line	:	1169 EASTERN PKWY
Second Line	:	STE 1234
City	:	LOUISVILLE
State	:	KY
Zip	:	40217-1462
Country	:	US
Telephone Number	:	502-456-3990
Fax Number	:	502-456-3988

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HENRY JAMES WALTER
Credential	:	MD
Telephone Number	:	502-456-3990

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	03/12/2010

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