Provider Demographics
NPI:1356447866
Name:BLUEGRASS NEUROLOGICAL SERVICES, PSC
Entity Type:Organization
Organization Name:BLUEGRASS NEUROLOGICAL SERVICES, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:317-567-2180
Mailing Address - Street 1:9899 E 126TH ST
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2821
Mailing Address - Country:US
Mailing Address - Phone:317-567-2179
Mailing Address - Fax:317-567-2191
Practice Address - Street 1:321 S 3RD ST
Practice Address - Street 2:SUITE A
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2001
Practice Address - Country:US
Practice Address - Phone:859-936-0094
Practice Address - Fax:859-936-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY381022084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200378110Medicaid
KY64069156Medicaid
KY64069156Medicaid