Provider Demographics
NPI:1073767737
Name:BLUE GRASS DIAGNOSTICS
Entity Type:Organization
Organization Name:BLUE GRASS DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-568-1100
Mailing Address - Street 1:P.O. BOX 0907
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0937
Mailing Address - Country:US
Mailing Address - Phone:502-568-1000
Mailing Address - Fax:502-736-9369
Practice Address - Street 1:820 S. 6TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203
Practice Address - Country:US
Practice Address - Phone:502-568-1000
Practice Address - Fax:502-736-9369
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROGRESSIVE MEDICAL & REHABILITATION GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-07
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty