Basic Information
| Provider Information | |||||||||
| NPI: | 1609074624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUEGRASS INTERNAL MEDICINE GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 870 CORPORATE DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405035416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592779436 | ||||||||
| FaxNumber: | 8592771765 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 HARRODSBURG RD | ||||||||
| Address2: | SUITE C435 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592771570 | ||||||||
| FaxNumber: | 8592771595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | AJELLO | ||||||||
| AuthorizedOfficialFirstName: | MARY BETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8592251339 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | DG3592 | 01 | KY | RR MEDICARE | OTHER | 7100002460 | 05 | KY | MEDICAID |