Provider Demographics
NPI:1427229707
Name:BLUEGRASS PEDIATRICS AND INTERNAL MEDICINE, PLLC
Entity Type:Organization
Organization Name:BLUEGRASS PEDIATRICS AND INTERNAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:P
Authorized Official - Last Name:BALBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-863-2818
Mailing Address - Street 1:196 BEVINS LN
Mailing Address - Street 2:SUITE F
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-8534
Mailing Address - Country:US
Mailing Address - Phone:502-863-2818
Mailing Address - Fax:502-863-2764
Practice Address - Street 1:196 BEVINS LN
Practice Address - Street 2:SUITE F
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8534
Practice Address - Country:US
Practice Address - Phone:502-863-2818
Practice Address - Fax:502-863-2764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41057207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100047760Medicaid
KY7100059860Medicaid
KY00664Medicare PIN