Provider Demographics
NPI:1831310390
Name:KENTUCKY DERMATOLOGY AND SKIN CANCER CLINIC, PSC
Entity Type:Organization
Organization Name:KENTUCKY DERMATOLOGY AND SKIN CANCER CLINIC, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:FENSTERMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-276-1511
Mailing Address - Street 1:177 BURT RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2410
Mailing Address - Country:US
Mailing Address - Phone:859-276-1511
Mailing Address - Fax:859-276-3373
Practice Address - Street 1:177 BURT RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2410
Practice Address - Country:US
Practice Address - Phone:859-276-1511
Practice Address - Fax:859-276-3373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC16315OtherRR MEDICARE
KY8436Medicare PIN
KY2026Medicare PIN