Provider Demographics
NPI:1013069301
Name:DERMATOLOGY SPECIALISTS, PSC
Entity type:Organization
Organization Name:DERMATOLOGY SPECIALISTS, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-583-7546
Mailing Address - Street 1:501 S 2ND ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2862
Mailing Address - Country:US
Mailing Address - Phone:502-583-7546
Mailing Address - Fax:502-589-3429
Practice Address - Street 1:501 S 2ND ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2862
Practice Address - Country:US
Practice Address - Phone:502-583-7546
Practice Address - Fax:502-589-3429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
KY207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7485OtherRRR MEDICARE
IN200044790BMedicaid
KY2433273000OtherPASSPORT ADVANTAGE
KY1052384OtherPASSPORT
KY3813Medicare PIN
IN265290Medicare PIN
IN200044790BMedicaid
IN330630Medicare PIN