Provider Demographics
NPI:1770643561
Name:BLUEGRASS GASTROENTEROLOGY, PSC
Entity Type:Organization
Organization Name:BLUEGRASS GASTROENTEROLOGY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:270-441-4701
Mailing Address - Street 1:225 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 307
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7914
Mailing Address - Country:US
Mailing Address - Phone:270-441-4701
Mailing Address - Fax:270-441-4707
Practice Address - Street 1:225 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 307
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7914
Practice Address - Country:US
Practice Address - Phone:270-441-4701
Practice Address - Fax:270-441-4707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65928459Medicaid
KY65928459Medicaid
IL607040Medicare PIN