Provider Demographics
NPI:1932255569
Name:S RANDOLPH SCHEEN III MD PSC INC
Entity Type:Organization
Organization Name:S RANDOLPH SCHEEN III MD PSC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:SCHEEN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:502-893-1645
Mailing Address - Street 1:4121 DUTCHMANS LANE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207
Mailing Address - Country:US
Mailing Address - Phone:502-893-1645
Mailing Address - Fax:502-897-2338
Practice Address - Street 1:4121 DUTCHMANS LANE
Practice Address - Street 2:SUITE 401
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-893-1645
Practice Address - Fax:502-897-2338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21343207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000358728OtherANTHEM
P00204656 DD0297OtherRR MEDICARE
P00204656 DD0297OtherRR MEDICARE
0960601Medicare ID - Type Unspecified