Provider Demographics
NPI:1043414873
Name:BLUEGRASS ORTHOPAEDIC GROUP PSC
Entity Type:Organization
Organization Name:BLUEGRASS ORTHOPAEDIC GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-895-1489
Mailing Address - Street 1:3920 DUTCHMANS LN
Mailing Address - Street 2:SUITE 314
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4702
Mailing Address - Country:US
Mailing Address - Phone:502-895-1489
Mailing Address - Fax:502-895-1261
Practice Address - Street 1:3920 DUTCHMANS LN
Practice Address - Street 2:SUITE 314
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4702
Practice Address - Country:US
Practice Address - Phone:502-895-1489
Practice Address - Fax:502-895-1261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2782Medicare ID - Type Unspecified