Provider Demographics
NPI:1497814768
Name:BLUEGRASS SURGICAL ASSOCIATION, PSC
Entity Type:Organization
Organization Name:BLUEGRASS SURGICAL ASSOCIATION, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:KORBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-782-5219
Mailing Address - Street 1:996 WILKINSON TRCE
Mailing Address - Street 2:SUITE A5
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-3407
Mailing Address - Country:US
Mailing Address - Phone:270-782-5219
Mailing Address - Fax:270-793-9385
Practice Address - Street 1:996 WILKINSON TRCE
Practice Address - Street 2:SUITE A5
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-3407
Practice Address - Country:US
Practice Address - Phone:270-782-5219
Practice Address - Fax:270-793-9385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25747174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65924375Medicaid
KY65924375Medicaid