Provider Demographics
NPI:1821130295
Name:OWENSBORO DERMATOLOGY ASSOCIATES, PSC
Entity Type:Organization
Organization Name:OWENSBORO DERMATOLOGY ASSOCIATES, PSC
Other - Org Name:HENDERSON DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLERICAL SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:GIRTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-685-5777
Mailing Address - Street 1:2821 NEW HARTFORD RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1320
Mailing Address - Country:US
Mailing Address - Phone:270-685-5777
Mailing Address - Fax:270-685-0190
Practice Address - Street 1:2821 NEW HARTFORD RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1320
Practice Address - Country:US
Practice Address - Phone:270-685-5777
Practice Address - Fax:270-685-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6592778200Medicaid
KY3956Medicare ID - Type Unspecified