Provider Demographics
NPI:1558553560
Name:ADVANCED CLINICAL DERMATOLOGY, PSC
Entity Type:Organization
Organization Name:ADVANCED CLINICAL DERMATOLOGY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-288-5004
Mailing Address - Street 1:1401 HARRODSBURG RD
Mailing Address - Street 2:SUITE C415
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3751
Mailing Address - Country:US
Mailing Address - Phone:859-288-5004
Mailing Address - Fax:859-288-5007
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:SUITE C415
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-288-5004
Practice Address - Fax:859-288-5007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40054261QM2500X
KYPA602363AM0700X
KY3688P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100090760Medicaid
KY1033189295OtherINDIVIDUAL NPI
KYDN1298OtherRAILROAD MEDICARE
KY1033189295OtherINDIVIDUAL NPI