Provider Demographics
NPI:1639263338
Name:BLUEGRASS PAIN MANAGEMENT, PSC
Entity Type:Organization
Organization Name:BLUEGRASS PAIN MANAGEMENT, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOSOMWORTH
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:859-275-5229
Mailing Address - Street 1:1760 NICHOLASVILLE ROAD
Mailing Address - Street 2:SUITE 503
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503
Mailing Address - Country:US
Mailing Address - Phone:859-275-5229
Mailing Address - Fax:859-977-2683
Practice Address - Street 1:1760 NICHOLASVILLE ROAD
Practice Address - Street 2:SUITE 503
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503
Practice Address - Country:US
Practice Address - Phone:859-275-5229
Practice Address - Fax:859-977-2683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65941361Medicaid
KY9174Medicare ID - Type Unspecified