Provider Demographics
NPI:1225048416
Name:BLUEGRASS EAR NOSE & THROAT CLINIC
Entity Type:Organization
Organization Name:BLUEGRASS EAR NOSE & THROAT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARA
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:MAKDESSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-745-1010
Mailing Address - Street 1:205 FLOYD CLAY DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-1156
Mailing Address - Country:US
Mailing Address - Phone:859-745-1010
Mailing Address - Fax:859-745-0080
Practice Address - Street 1:205 FLOYD CLAY DR
Practice Address - Street 2:SUITE 3
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1156
Practice Address - Country:US
Practice Address - Phone:859-745-1010
Practice Address - Fax:859-745-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207Y00000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYH55546Medicare UPIN
KY9579Medicare PIN