Provider Demographics
NPI:1609994789
Name:BLUEGRASS REGIONAL HEALTHCARE
Entity Type:Organization
Organization Name:BLUEGRASS REGIONAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:270-274-9222
Mailing Address - Street 1:1307 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-8957
Mailing Address - Country:US
Mailing Address - Phone:270-274-9222
Mailing Address - Fax:270-274-0696
Practice Address - Street 1:1307 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-8957
Practice Address - Country:US
Practice Address - Phone:270-274-9222
Practice Address - Fax:270-274-0696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2835P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2835POtherLICENSE
KY78006764Medicaid
KY2835POtherLICENSE
KY78006764Medicaid