Provider Demographics
NPI:1881030088
Name:FACIAL PLASTIC SURGERY & DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:FACIAL PLASTIC SURGERY & DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:PRUDEN
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:859-226-0206
Mailing Address - Street 1:3070 LAKECREST CIR
Mailing Address - Street 2:STE. 400-264
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1937
Mailing Address - Country:US
Mailing Address - Phone:859-226-0206
Mailing Address - Fax:859-226-0207
Practice Address - Street 1:448 LEWIS HARGETT CIR
Practice Address - Street 2:STE 240
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3594
Practice Address - Country:US
Practice Address - Phone:859-226-0206
Practice Address - Fax:859-226-0207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-14
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34192207N00000X, 207ND0101X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000823139OtherANTHEM BCBS
KY7100245900Medicaid
KYK001521Medicare PIN