MEDICARE: BLUEGRASS FOOT AND ANKLE CARE

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	213ES0103X	Foot & Ankle Surgery Podiatrist	00274	KY
2	332BC3200X	Customized Equipment (DME)	00274	KY

General Provider Information

NPI Number	:	1972783157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEGRASS FOOT AND ANKLE CARE

Provider Business Mailing Address
First Line	:	326 HIGHLAND PARK DR
Second Line	:
City	:	RICHMOND
State	:	KY
Zip	:	40475-3487
Country	:	US
Telephone Number	:	859-623-3550
Fax Number	:

Provider Business Practice Location Address
First Line	:	326 HIGHLAND PARK DR
Second Line	:
City	:	RICHMOND
State	:	KY
Zip	:	40475-3487
Country	:	US
Telephone Number	:	859-623-3550
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DPM
Name	:	DR. RANDALL W HALL
Credential	:	DPM
Telephone Number	:	859-623-3550

Provider Enumeration Date	:	11/06/2007
Last Update Date	:	09/19/2019

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1215935671 — DR. RANDALL WAYNE HALL D.P.M.
Practice Location Address:

326 HIGHLAND PARK DR
RICHMOND, KY
40475-3487

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1598896334 — BLUEGRASS FOOT AND ANKLE CARE, PLLC
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Practice Location Address:

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1083997886 — SAMANTHA UPSHAW MAXEY
Practice Location Address:

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