Provider Demographics
NPI:1013925106
Name:SKIN GROUP PLLC
Entity type:Organization
Organization Name:SKIN GROUP PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VILMA
Authorized Official - Middle Name:C
Authorized Official - Last Name:FABRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-495-1162
Mailing Address - Street 1:444 S 1ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1474
Mailing Address - Country:US
Mailing Address - Phone:502-495-1162
Mailing Address - Fax:502-495-0165
Practice Address - Street 1:2211 GREENE WAY
Practice Address - Street 2:STE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-4076
Practice Address - Country:US
Practice Address - Phone:502-495-1162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26062207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4016601Medicare PIN