Provider Demographics
NPI:1720477672
Name:BLUEGRASS PODIATRIC MANAGEMENT LLC
Entity Type:Organization
Organization Name:BLUEGRASS PODIATRIC MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LASORELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-829-9333
Mailing Address - Street 1:178 N EWING AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2459
Mailing Address - Country:US
Mailing Address - Phone:502-554-3792
Mailing Address - Fax:
Practice Address - Street 1:178 N EWING AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-2459
Practice Address - Country:US
Practice Address - Phone:502-554-3792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-15
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00379213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100335760Medicaid
KYDV4440Medicare PIN
KYK187850Medicare PIN