Provider Demographics
NPI:1275687873
Name:DERMATOLOGY ASSOCIATES OF KENTUCKY, PSC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF KENTUCKY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-263-4444
Mailing Address - Street 1:250 FOUNTAIN CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1888
Mailing Address - Country:US
Mailing Address - Phone:859-263-4444
Mailing Address - Fax:859-543-8867
Practice Address - Street 1:250 FOUNTAIN CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1888
Practice Address - Country:US
Practice Address - Phone:859-263-4444
Practice Address - Fax:859-543-8867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY300149261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000304454OtherANTHEM BLUE CROSS & BLUE SHIELD
000000304454OtherANTHEM
KY000000304454OtherANTHEM BLUE CROSS & BLUE SHIELD
KY490005771Medicare PIN