Provider Demographics
NPI:1689401465
Name:PADUCAH DERMATOLOGY SURGERY CENTER PLLC
Entity type:Organization
Organization Name:PADUCAH DERMATOLOGY SURGERY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-444-8477
Mailing Address - Street 1:127 ALBEN BARKLEY DRIVE SUITE A
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001
Mailing Address - Country:US
Mailing Address - Phone:270-444-8477
Mailing Address - Fax:270-444-8479
Practice Address - Street 1:127 ALBEN BARKLEY DRIVE SUITE A
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001
Practice Address - Country:US
Practice Address - Phone:270-444-8477
Practice Address - Fax:270-444-8479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-17
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical