Provider Demographics
NPI:1629497714
Name:SKINMD
Entity Type:Organization
Organization Name:SKINMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-276-7546
Mailing Address - Street 1:200 NORTHLAND BLVD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3604
Mailing Address - Country:US
Mailing Address - Phone:513-672-4111
Mailing Address - Fax:513-672-4468
Practice Address - Street 1:989 GOVERNORS LN
Practice Address - Street 2:SUITE 220
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1173
Practice Address - Country:US
Practice Address - Phone:859-296-7546
Practice Address - Fax:513-672-3323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK133600Medicare PIN