Provider Demographics
NPI:1235343419
Name:PIKEVILLE DERMATOLOGY & COSMETIC CENTER, PSC
Entity Type:Organization
Organization Name:PIKEVILLE DERMATOLOGY & COSMETIC CENTER, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAVENDER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:606-432-9106
Mailing Address - Street 1:108 N AUXIER AVE
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-9045
Mailing Address - Country:US
Mailing Address - Phone:606-432-9106
Mailing Address - Fax:606-432-0967
Practice Address - Street 1:108 N AUXIER AVE
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-9045
Practice Address - Country:US
Practice Address - Phone:606-432-9106
Practice Address - Fax:606-432-0967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02627207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5900011000Medicaid
VA010250030Medicaid
KY64005812Medicaid
KY64005812Medicaid
KY9981Medicare PIN