Provider Demographics
NPI:1275271694
Name:BLUEGRASS REGIONAL FOOT AND ANKLE ASSOCIATES PSC
Entity Type:Organization
Organization Name:BLUEGRASS REGIONAL FOOT AND ANKLE ASSOCIATES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:KRESTIK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:606-862-9900
Mailing Address - Street 1:1105 W. 5TH STREET
Mailing Address - Street 2:#3
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-1610
Mailing Address - Country:US
Mailing Address - Phone:606-862-9900
Mailing Address - Fax:606-862-8901
Practice Address - Street 1:1907 EAST PITTSBURGH CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741
Practice Address - Country:US
Practice Address - Phone:606-260-8590
Practice Address - Fax:606-260-8591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-25
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90005737Medicaid