Provider Demographics
NPI:1255851200
Name:REGIONAL DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:REGIONAL DERMATOLOGY PLLC
Other - Org Name:SKIN MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PRUDEN
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:859-296-7546
Mailing Address - Street 1:989 GOVERNORS LN STE 220
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1175
Mailing Address - Country:US
Mailing Address - Phone:859-296-7546
Mailing Address - Fax:859-721-0829
Practice Address - Street 1:989 GOVERNORS LN STE 220
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1175
Practice Address - Country:US
Practice Address - Phone:859-296-7546
Practice Address - Fax:859-721-0829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34192207ND0101X, 207ND0900X, 207Y00000X, 208200000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty