1750564530 NPI number — PHYSICIANS SKIN CARE PLLC

Table of content: (NPI 1750564530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750564530 NPI number — PHYSICIANS SKIN CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS SKIN CARE PLLC
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:
PLLC
Provider Other Organization Name Type Code:
5
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:
1750564530
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1169 EASTERN PARKWAY
Provider Second Line Business Mailing Address:
SUIT #2310
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-451-9000
Provider Business Mailing Address Fax Number:
502-456-2728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1169 EASTERN PARKWAY
Provider Second Line Business Practice Location Address:
SUITE #2310
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-451-9000
Provider Business Practice Location Address Fax Number:
502-456-2728
Provider Enumeration Date:
12/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIRCIK
Authorized Official First Name:
LEON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER SOLE PROPRIETOR
Authorized Official Telephone Number:
502-451-9000

Provider Taxonomy Codes

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

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

  • Identifier: CJ6680 . This is a "MEDICARE RAILROAD PALMETT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000216151 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1156019 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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