Provider Demographics
NPI:1396859260
Name:BLUEGRASS RETINA CONSULTANTS, PSC
Entity Type:Organization
Organization Name:BLUEGRASS RETINA CONSULTANTS, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELIA
Authorized Official - Middle Name:F
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-264-0445
Mailing Address - Street 1:3290 BLAZER PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2169
Mailing Address - Country:US
Mailing Address - Phone:859-264-0445
Mailing Address - Fax:859-264-0447
Practice Address - Street 1:3290 BLAZER PKWY STE 100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2169
Practice Address - Country:US
Practice Address - Phone:859-264-0445
Practice Address - Fax:859-264-0447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000496249OtherBCBS
KY64341944Medicaid
KYDF7401Medicare PIN
KY64341944Medicaid
KY00197Medicare PIN