Basic Information
| Provider Information | |||||||||
| NPI: | 1134345481 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUEGRASS CARDIOLOGY PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 793 EASTERN BYPASS | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | RICHMOND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596241826 | ||||||||
| FaxNumber: | 8596241744 | ||||||||
| Practice Location | |||||||||
| Address1: | 793 EASTERN BYPASS | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | RICHMOND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596241826 | ||||||||
| FaxNumber: | 8596241744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 02/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | MORRIS | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CORP PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8596241826 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 02196 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 000000050520 | 01 | KY | ANTHEM | OTHER | 65931958 | 05 | KY | MEDICAID | CG1685 | 01 | KY | RAILROAD MEDICARE | OTHER |