Provider Demographics
NPI:1912162959
Name:BLUEGRASS RURAL HEALTH CLINIC, PSC
Entity Type:Organization
Organization Name:BLUEGRASS RURAL HEALTH CLINIC, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KISHORE
Authorized Official - Middle Name:
Authorized Official - Last Name:JADHAV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-658-2710
Mailing Address - Street 1:151 N EAGLE CREEK DR
Mailing Address - Street 2:STE 12
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1889
Mailing Address - Country:US
Mailing Address - Phone:859-263-4341
Mailing Address - Fax:859-263-7441
Practice Address - Street 1:2734 S HIGHWAY 421
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-7515
Practice Address - Country:US
Practice Address - Phone:606-658-2710
Practice Address - Fax:606-658-2712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33372207R00000X
KY255P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty