Provider Demographics
NPI:1104106954
Name:BLUEGRASS URGENT CARE LLC
Entity type:Organization
Organization Name:BLUEGRASS URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-485-7900
Mailing Address - Street 1:625 CHESTNUT DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WALTON
Mailing Address - State:KY
Mailing Address - Zip Code:41094-7845
Mailing Address - Country:US
Mailing Address - Phone:859-485-7900
Mailing Address - Fax:859-485-7920
Practice Address - Street 1:625 CHESTNUT DR
Practice Address - Street 2:SUITE 106
Practice Address - City:WALTON
Practice Address - State:KY
Practice Address - Zip Code:41094-7845
Practice Address - Country:US
Practice Address - Phone:859-485-7900
Practice Address - Fax:859-485-7920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100356480Medicaid
OH0111587Medicaid
OH0144553Medicaid
OH2274177Medicaid
KY7100108440Medicaid
KY7100204520Medicaid
KY7100217560Medicaid
KY7100351060Medicaid