Provider Demographics
NPI:1275580888
Name:WEST KENTUCKY DERMATOLOGY, PSC
Entity Type:Organization
Organization Name:WEST KENTUCKY DERMATOLOGY, PSC
Other - Org Name:WEST KENTUCKY DERMATOLOGY, PSC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:270-821-0066
Mailing Address - Street 1:95 YMCA DR STE 3
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-9035
Mailing Address - Country:US
Mailing Address - Phone:270-821-0066
Mailing Address - Fax:270-821-6580
Practice Address - Street 1:1851 N ORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-9007
Practice Address - Country:US
Practice Address - Phone:270-821-0066
Practice Address - Fax:270-821-6580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78904885Medicaid
KY65943334Medicaid
KY95901203Medicaid
KY65943334Medicaid