Provider Demographics
NPI:1255468872
Name:EAST LOUISVILLE DERMATOLOGY, PSC
Entity Type:Organization
Organization Name:EAST LOUISVILLE DERMATOLOGY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-426-9565
Mailing Address - Street 1:4912 US HIGHWAY 42
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-6349
Mailing Address - Country:US
Mailing Address - Phone:502-426-9565
Mailing Address - Fax:502-425-3240
Practice Address - Street 1:4912 US HIGHWAY 42
Practice Address - Street 2:SUITE 208
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-6349
Practice Address - Country:US
Practice Address - Phone:502-426-9565
Practice Address - Fax:502-425-3240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24086207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY=========OtherTAX ID NUMBER
KY2518Medicare ID - Type UnspecifiedMEDICARE GROUP ID