Provider Demographics
NPI:1669539789
Name:LOUISVILLE DERMATOLOGY ASC PSC
Entity type:Organization
Organization Name:LOUISVILLE DERMATOLOGY ASC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:LOGSDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-363-1841
Mailing Address - Street 1:1700 BLUEGRASS AVENUE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215
Mailing Address - Country:US
Mailing Address - Phone:502-363-1841
Mailing Address - Fax:502-366-3317
Practice Address - Street 1:1700 BLUEGRASS AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215
Practice Address - Country:US
Practice Address - Phone:502-363-1841
Practice Address - Fax:502-366-3317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65943797Medicaid
50005707OtherPASSPORT
KY65943797Medicaid