Provider Demographics
NPI:1609074624
Name:BLUEGRASS INTERNAL MEDICINE GROUP
Entity Type:Organization
Organization Name:BLUEGRASS INTERNAL MEDICINE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:AJELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-225-1339
Mailing Address - Street 1:870 CORPORATE DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-5416
Mailing Address - Country:US
Mailing Address - Phone:859-277-9436
Mailing Address - Fax:859-277-1765
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:SUITE C435
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-277-1570
Practice Address - Fax:859-277-1595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYDG3592OtherRR MEDICARE
KY7100002460Medicaid
KY7100002460Medicaid