Provider Demographics
NPI:1578560181
Name:DERMATOLOGY ASSOCIATES , PSC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES , PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-896-6355
Mailing Address - Street 1:PO BOX 950266
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0266
Mailing Address - Country:US
Mailing Address - Phone:502-896-6355
Mailing Address - Fax:502-896-6357
Practice Address - Street 1:2811 KLEMPNER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205
Practice Address - Country:US
Practice Address - Phone:502-896-6355
Practice Address - Fax:502-896-6357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-29
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4884OtherMEDICARE
KY65921173Medicaid
KY1090732OtherPASSPORT
KY2435933000OtherPASSPORT ADVANTAGE
KYCL4950OtherMEDICARE RAIL ROAD
KYCL4950OtherMEDICARE RAILROAD
KY4884OtherMEDICARE