Provider Demographics
NPI:1811663198
Name:PROVEN COSMETIC DERMATOLOGY
Entity type:Organization
Organization Name:PROVEN COSMETIC DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSHELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-802-4932
Mailing Address - Street 1:7766 EWING BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-7538
Mailing Address - Country:US
Mailing Address - Phone:859-283-1033
Mailing Address - Fax:859-283-1066
Practice Address - Street 1:7766 EWING BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-7538
Practice Address - Country:US
Practice Address - Phone:859-283-1033
Practice Address - Fax:859-283-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty