Provider Demographics
NPI:1629197397
Name:DERMATOLOGY ASSOCIATES OF NORTHERN KENTUCKY PSC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF NORTHERN KENTUCKY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-283-1033
Mailing Address - Street 1:7766 EWING BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-7538
Mailing Address - Country:US
Mailing Address - Phone:859-283-1033
Mailing Address - Fax:859-283-1066
Practice Address - Street 1:7766 EWING BLVD
Practice Address - Street 2:STE 100
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-7538
Practice Address - Country:US
Practice Address - Phone:859-283-1033
Practice Address - Fax:859-283-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
18D0324336OtherCLIA ID
18D0324336OtherCLIA ID