Provider Demographics
NPI:1477646446
Name:BEARGRASS MEDICAL ASSOCIATES PSC
Entity Type:Organization
Organization Name:BEARGRASS MEDICAL ASSOCIATES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-456-3990
Mailing Address - Street 1:1169 EASTERN PKWY
Mailing Address - Street 2:STE 1234
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1462
Mailing Address - Country:US
Mailing Address - Phone:502-456-3990
Mailing Address - Fax:502-456-3988
Practice Address - Street 1:1169 EASTERN PKWY
Practice Address - Street 2:STE 1234
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1462
Practice Address - Country:US
Practice Address - Phone:502-456-3990
Practice Address - Fax:502-456-3988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
215554207R00000X
17516207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5843Medicare PIN