1578560181 NPI number — DERMATOLOGY ASSOCIATES , PSC

Table of content: (NPI 1578560181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578560181 NPI number — DERMATOLOGY ASSOCIATES , PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY ASSOCIATES , PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578560181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 950266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40295-0266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-896-6355
Provider Business Mailing Address Fax Number:
502-896-6357

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2811 KLEMPNER WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-896-6355
Provider Business Practice Location Address Fax Number:
502-896-6357
Provider Enumeration Date:
06/29/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WHITEHOUSE
Authorized Official First Name:
ANNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATION
Authorized Official Telephone Number:
502-896-6355

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4884 . This is a "MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: CL4950 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65921173 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1090732 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2435933000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: CL4950 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".