Basic Information
| Provider Information | |||||||||
| NPI: | 1861118895 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUEGRASS MED CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4863 SCOTTSVILLE RD STE B | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421047949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708435662 | ||||||||
| FaxNumber: | 2708435614 | ||||||||
| Practice Location | |||||||||
| Address1: | 4863 SCOTTSVILLE RD STE B | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421047949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708435662 | ||||||||
| FaxNumber: | 2708435614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2022 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | LANHAM | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2708435662 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 7100796090 | 05 | KY | MEDICAID | 64250715 | 05 | KY | MEDICAID | 7100561960 | 05 | KY | MEDICAID |