Provider Demographics
NPI:1164460051
Name:EASTERN KENTUCKY UNIVERSITY
Entity Type:Organization
Organization Name:EASTERN KENTUCKY UNIVERSITY
Other - Org Name:BLUEGRASS COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:FISTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:859-259-0717
Mailing Address - Street 1:1306 VERSAILLES RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1117
Mailing Address - Country:US
Mailing Address - Phone:859-259-0717
Mailing Address - Fax:859-254-7874
Practice Address - Street 1:1306 VERSAILLES RD
Practice Address - Street 2:SUITE 120
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1117
Practice Address - Country:US
Practice Address - Phone:859-259-0717
Practice Address - Fax:859-254-7874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700160261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000537566OtherANTHEM
KY31001118Medicaid
KY9968164OtherAETNA
KY181870Medicare PIN
KYK096840Medicare PIN
KYP10002410Medicare PIN