Provider Demographics
NPI:1396044301
Name:BLUE CRESCENT-BLUE STAR MEDICAL OF KENTUCKY, INC
Entity Type:Organization
Organization Name:BLUE CRESCENT-BLUE STAR MEDICAL OF KENTUCKY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNDIATA
Authorized Official - Middle Name:M
Authorized Official - Last Name:EL-AMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-823-0000
Mailing Address - Street 1:95 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DRY RIDGE
Mailing Address - State:KY
Mailing Address - Zip Code:41035-7343
Mailing Address - Country:US
Mailing Address - Phone:859-823-0000
Mailing Address - Fax:
Practice Address - Street 1:95 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DRY RIDGE
Practice Address - State:KY
Practice Address - Zip Code:41035-7343
Practice Address - Country:US
Practice Address - Phone:859-823-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21770KY207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty