Provider Demographics
NPI:1982755682
Name:BLUEGRASS SPINE CARE, PSC
Entity type:Organization
Organization Name:BLUEGRASS SPINE CARE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-633-0192
Mailing Address - Street 1:1741 MIDLAND TRL
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1711
Mailing Address - Country:US
Mailing Address - Phone:502-633-0192
Mailing Address - Fax:502-633-4164
Practice Address - Street 1:1741 MIDLAND TRL
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1711
Practice Address - Country:US
Practice Address - Phone:502-633-0192
Practice Address - Fax:502-633-4164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32619207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1063266OtherPASSPORT
KY000802487OtherHUMANA
KY122601OtherCHA
KY2434349000OtherPASSPORT ADVANTAGE
KY5344332OtherAETNA
KY65930299Medicaid
KY5134693001OtherCIGNA
KY2434349000OtherPASSPORT ADVANTAGE
KY5344332OtherAETNA
KYG11574Medicare UPIN
KY5246Medicare PIN