Basic Information
| Provider Information | |||||||||
| NPI: | 1164460051 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTERN KENTUCKY UNIVERSITY | ||||||||
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| OtherOrganizationName: | BLUEGRASS COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1306 VERSAILLES RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592590717 | ||||||||
| FaxNumber: | 8592547874 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 VERSAILLES RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592590717 | ||||||||
| FaxNumber: | 8592547874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 08/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | FISTER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8592590717 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 700160 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 000000537566 | 01 | KY | ANTHEM | OTHER | 31001118 | 05 | KY | MEDICAID | 9968164 | 01 | KY | AETNA | OTHER |