Provider Demographics
NPI:1801823828
Name:BLUEGRASS REGIONAL PSYCHIATRIC SERVICES INC.
Entity Type:Organization
Organization Name:BLUEGRASS REGIONAL PSYCHIATRIC SERVICES INC.
Other - Org Name:EASTERN STATE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FISCAL OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ODUSANYA
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:859-246-7363
Mailing Address - Street 1:627 W FOURTH ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-1294
Mailing Address - Country:US
Mailing Address - Phone:859-246-7363
Mailing Address - Fax:859-246-7023
Practice Address - Street 1:627 W FOURTH ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-1294
Practice Address - Country:US
Practice Address - Phone:859-246-7363
Practice Address - Fax:859-246-7023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0410Medicare ID - Type UnspecifiedMEDICARE B
KY184004Medicare ID - Type UnspecifiedMDEICARE A
KYCA0974Medicare ID - Type UnspecifiedRAILROAD MEDICARE