Provider Demographics
NPI:1669636486
Name:BLUEGRASS REGIONAL IMAGING LLC
Entity Type:Organization
Organization Name:BLUEGRASS REGIONAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOSTELIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-219-0542
Mailing Address - Street 1:1218 S BROADWAY
Mailing Address - Street 2:STE 310
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2759
Mailing Address - Country:US
Mailing Address - Phone:859-219-0542
Mailing Address - Fax:859-219-9433
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:C45
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-276-2157
Practice Address - Fax:859-276-4938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000219100OtherANTHEM
KY65935207Medicaid
KY000000219100OtherANTHEM
KY65935207Medicaid