Provider Demographics
NPI:1164518130
Name:BLUEGRASS MEDICAL GROUP PSC
Entity Type:Organization
Organization Name:BLUEGRASS MEDICAL GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-277-8560
Mailing Address - Street 1:1451 HARRODSBURG RD
Mailing Address - Street 2:SUITE D 502
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3758
Mailing Address - Country:US
Mailing Address - Phone:859-277-8560
Mailing Address - Fax:859-277-8866
Practice Address - Street 1:1451 HARRODSBURG RD
Practice Address - Street 2:SUITE D 502
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3758
Practice Address - Country:US
Practice Address - Phone:859-277-8560
Practice Address - Fax:859-277-8866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25337174400000X
KY26673174400000X
KY41917207Q00000X
207Q00000X, 207R00000X, 363L00000X, 363LF0000X
KY3005655364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000055841OtherANTHEM
KY64253370Medicaid
KY65905234Medicaid
KYC78343Medicare UPIN
D55148Medicare UPIN
KY65905234Medicaid
KYH65571Medicare UPIN
KY6207Medicare PIN
KYC69350Medicare UPIN
KY64253370Medicaid
KYE71064Medicare UPIN
KY64266737Medicaid