Provider Demographics
NPI:1023217197
Name:BLUEGRASS ORTHOPEDIC GROUP PSC
Entity Type:Organization
Organization Name:BLUEGRASS ORTHOPEDIC GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-222-0598
Mailing Address - Street 1:1023 NEW MOODY LN
Mailing Address - Street 2:STE 102
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9177
Mailing Address - Country:US
Mailing Address - Phone:502-222-0598
Mailing Address - Fax:502-222-7446
Practice Address - Street 1:1023 NEW MOODY LN
Practice Address - Street 2:STE 102
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9177
Practice Address - Country:US
Practice Address - Phone:502-222-0598
Practice Address - Fax:502-222-7446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23227174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0975Medicare PIN