Basic Information
| Provider Information | |||||||||
| NPI: | 1659860807 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUEGRASS MEDICAL CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4863B SCOTTSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421047909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708435662 | ||||||||
| FaxNumber: | 2708435614 | ||||||||
| Practice Location | |||||||||
| Address1: | 4863B SCOTTSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421047909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708435662 | ||||||||
| FaxNumber: | 2708435614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2018 | ||||||||
| LastUpdateDate: | 05/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | JESSEE | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2706703520 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.