Provider Demographics
NPI:1265571020
Name:BLUEGRASS CLINIC STANFORD, PLLC
Entity type:Organization
Organization Name:BLUEGRASS CLINIC STANFORD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:606-365-8338
Mailing Address - Street 1:107 METKER TRL
Mailing Address - Street 2:SUITE A
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484-1049
Mailing Address - Country:US
Mailing Address - Phone:606-365-8338
Mailing Address - Fax:
Practice Address - Street 1:107 METKER TRL
Practice Address - Street 2:SUITE A
Practice Address - City:STANFORD
Practice Address - State:KY
Practice Address - Zip Code:40484-1049
Practice Address - Country:US
Practice Address - Phone:606-365-8338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30199173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35001882Medicaid
KYDE0433OtherRR MEDICARE GROUP NUMBER
KY0988503Medicare PIN
KY9885Medicare PIN
KY183939Medicare PIN