Provider Demographics
NPI:1134140759
Name:ON-SITE DERMATOLOGY CONSULTANTS
Entity type:Organization
Organization Name:ON-SITE DERMATOLOGY CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MADER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:502-322-6678
Mailing Address - Street 1:11209 VISTA GREENS DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-3444
Mailing Address - Country:US
Mailing Address - Phone:502-322-6678
Mailing Address - Fax:502-394-0086
Practice Address - Street 1:11209 VISTA GREENS DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-3444
Practice Address - Country:US
Practice Address - Phone:502-322-6678
Practice Address - Fax:502-394-0086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4150P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYDF3020OtherRAILROAD MEDICARE
KY000000484649OtherANTHEM
KY78905320Medicaid
KY=========OtherTRICARE
KY=========OtherTRICARE