Provider Demographics
NPI:1336101179
Name:PURCHASE DERM-ENT, PLLC
Entity Type:Organization
Organization Name:PURCHASE DERM-ENT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:C
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-408-4368
Mailing Address - Street 1:2605 KENTUCKY AVENUE
Mailing Address - Street 2:DOB 3, SUITE 601
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3800
Mailing Address - Country:US
Mailing Address - Phone:270-408-4368
Mailing Address - Fax:570-408-3272
Practice Address - Street 1:2605 KENTUCKY AVENUE
Practice Address - Street 2:DOB 3, SUITE 601
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3800
Practice Address - Country:US
Practice Address - Phone:270-408-4368
Practice Address - Fax:570-408-3272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100198720Medicaid
KY78903721Medicaid
KY5897Medicare PIN
KY78903721Medicaid