Provider Demographics
NPI:1942463096
Name:PRIMARY CARE OF THE BLUEGRASS, LLC
Entity Type:Organization
Organization Name:PRIMARY CARE OF THE BLUEGRASS, LLC
Other - Org Name:CRAB ORCHARD PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:859-303-8746
Mailing Address - Street 1:1031 WELLINGTON WAY STE 240
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1257
Mailing Address - Country:US
Mailing Address - Phone:859-303-8746
Mailing Address - Fax:
Practice Address - Street 1:29 MAIN ST
Practice Address - Street 2:
Practice Address - City:CRAB ORCHARD
Practice Address - State:KY
Practice Address - Zip Code:40419-6548
Practice Address - Country:US
Practice Address - Phone:606-355-7800
Practice Address - Fax:606-355-7803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700193261QP2300X
KY900266261QR1300X
363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100043870Medicaid
KY00727Medicare PIN