Provider Demographics
NPI:1730352972
Name:BLUEGRASS PAIN CONSULTANTS PLLC
Entity type:Organization
Organization Name:BLUEGRASS PAIN CONSULTANTS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-423-1021
Mailing Address - Street 1:10301 CHAMPION FARMS DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-6129
Mailing Address - Country:US
Mailing Address - Phone:502-423-1021
Mailing Address - Fax:502-423-1416
Practice Address - Street 1:10241 CHAMPION FARMS DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6150
Practice Address - Country:US
Practice Address - Phone:502-423-1021
Practice Address - Fax:502-423-1416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100038680Medicaid
KY7100034210Medicaid
KY00635Medicare PIN