Provider Demographics
NPI:1649222969
Name:BLUEGRASS PRIMARY CARE LLC
Entity Type:Organization
Organization Name:BLUEGRASS PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-219-2828
Mailing Address - Street 1:P.O. BOX 23523
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40523-3523
Mailing Address - Country:US
Mailing Address - Phone:859-422-4363
Mailing Address - Fax:859-422-4357
Practice Address - Street 1:135 EAST MAKWELL ST.
Practice Address - Street 2:SUITE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508
Practice Address - Country:US
Practice Address - Phone:859-422-4363
Practice Address - Fax:859-422-4357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000004074OtherBCBS
KY78905098Medicaid
KY78905098Medicaid
KY0003Medicare PIN