Basic Information
| Provider Information | |||||||||
| NPI: | 1497735948 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUEGRASS REGIONAL CANCER CENTER LLP | ||||||||
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| OtherOrganizationName: | LOUISVILLE RADIATION ONCOLOGY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 CHURCHMAN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402151143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023633100 | ||||||||
| FaxNumber: | 5023631110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | COMMINS | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2399317275 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 65931693 | 05 | KY | MEDICAID | CK9008 | 01 | KY | RAILROAD MEDICARE | OTHER |