Basic Information
| Provider Information | |||||||||
| NPI: | 1396780078 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUEGRASS CARDIOLOGY CONSULTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 DIAGNOSTIC DR | ||||||||
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| City: | FRANKFORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 406016524 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 107 DIAGNOSTIC DR | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 406016524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028759885 | ||||||||
| FaxNumber: | 5028759882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 05/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | KYESHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5028759885 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 27319 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 64199441 | 05 | KY | MEDICAID | 64922230 | 05 | KY | MEDICAID | 522398578 | 01 | KY | ANDREW BUSTIN, MD TAX ID | OTHER | 64057623 | 05 | KY | MEDICAID |