Provider Demographics
NPI:1245401645
Name:UNIVERSITY DERMATOPATHOLOGY CONSULTANTS PSC
Entity Type:Organization
Organization Name:UNIVERSITY DERMATOPATHOLOGY CONSULTANTS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANINE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-569-7711
Mailing Address - Street 1:310 E BROADWAY
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1745
Mailing Address - Country:US
Mailing Address - Phone:502-569-7711
Mailing Address - Fax:502-587-8119
Practice Address - Street 1:310 E BROADWAY
Practice Address - Street 2:SUITE 3A
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1745
Practice Address - Country:US
Practice Address - Phone:502-569-7711
Practice Address - Fax:502-587-8119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY32113207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100062460Medicaid
KY3539028000OtherPASSPORT ADVANTAGE
KYDP2238OtherMEDICARE RR
IN200919370AMedicaid
KY50020526OtherPASSPORT
KY00771Medicare PIN