Basic Information
| Provider Information | |||||||||
| NPI: | 1932631629 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUEGRASS MOBILE MEDICAL SERVICES,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 168 E REYNOLDS RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405171317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595545067 | ||||||||
| FaxNumber: | 8598180324 | ||||||||
| Practice Location | |||||||||
| Address1: | 168 E REYNOLDS RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405171317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595545067 | ||||||||
| FaxNumber: | 8598180324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2017 | ||||||||
| LastUpdateDate: | 03/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | OWENS | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER,ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8597971112 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DNP, APRN, FNP-C | ||||||||
| NPICertificationDate: | 03/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1053225 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100471130 | 05 | KY | MEDICAID |