Provider Demographics
NPI:1598896334
Name:BLUEGRASS FOOT AND ANKLE CARE, PLLC
Entity Type:Organization
Organization Name:BLUEGRASS FOOT AND ANKLE CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:W
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:859-623-3550
Mailing Address - Street 1:326 HIGHLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3487
Mailing Address - Country:US
Mailing Address - Phone:859-623-3550
Mailing Address - Fax:859-623-3393
Practice Address - Street 1:326 HIGHLAND PARK DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3487
Practice Address - Country:US
Practice Address - Phone:859-623-3550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00274213E00000X, 332B00000X
KY00270213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90011214Medicaid
KY7100051420Medicaid
KY000000330835OtherANTHEM
KY5166730001Medicare NSC
KY9154Medicare PIN
KYDB944Medicare PIN