1578560181 NPI number — DERMATOLOGY ASSOCIATES , PSC

Table of content: RONALD OMEGA FORBES MD (NPI 1023096583)

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: 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 RAIL ROAD" 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".




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