Provider Demographics
NPI:1548217201
Name:COLBERT, ROGER K (CRNA)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:K
Last Name:COLBERT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1160
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-4160
Mailing Address - Country:US
Mailing Address - Phone:859-276-6611
Mailing Address - Fax:
Practice Address - Street 1:4305 NEW SHEPHERDSVILLE RD
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-9019
Practice Address - Country:US
Practice Address - Phone:502-350-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1053494367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000271994OtherBCBS
KY74346503Medicaid
KY0601380Medicare PIN
KYP00000029Medicare PIN
KY0735726Medicare PIN