MEDICARE: BLUEGRASS RURAL HEALTH CLINIC, 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	363L00000X	Nurse Practitioner	255P	KY
2	207R00000X	Internal Medicine Physician	33372	KY

General Provider Information

NPI Number	:	1912162959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEGRASS RURAL HEALTH CLINIC, PSC

Provider Business Mailing Address
First Line	:	151 N EAGLE CREEK DR
Second Line	:	STE 12
City	:	LEXINGTON
State	:	KY
Zip	:	40509-1889
Country	:	US
Telephone Number	:	859-263-4341
Fax Number	:	859-263-7441

Provider Business Practice Location Address
First Line	:	2734 S HIGHWAY 421
Second Line	:
City	:	MANCHESTER
State	:	KY
Zip	:	40962-7515
Country	:	US
Telephone Number	:	606-658-2710
Fax Number	:	606-658-2712

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KISHORE JADHAV
Credential	:	MD
Telephone Number	:	606-658-2710

Provider Enumeration Date	:	07/18/2008
Last Update Date	:	07/18/2008

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