Provider Demographics
NPI:1619973682
Name:BLUEGRASS INTERNAL MEDICINE PLLC
Entity type:Organization
Organization Name:BLUEGRASS INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:JARVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-685-1066
Mailing Address - Street 1:3346 PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4551
Mailing Address - Country:US
Mailing Address - Phone:270-685-1066
Mailing Address - Fax:270-685-0881
Practice Address - Street 1:3346 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4551
Practice Address - Country:US
Practice Address - Phone:270-685-1066
Practice Address - Fax:270-685-0881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65935470Medicaid
KY78902251Medicaid
KY78902251Medicaid