Provider Demographics
NPI:1053536037
Name:WEST KENTUCKY DERMATOLOGY, PSC
Entity type:Organization
Organization Name:WEST KENTUCKY DERMATOLOGY, PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:270-821-0066
Mailing Address - Street 1:1851 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-9007
Mailing Address - Country:US
Mailing Address - Phone:270-821-0066
Mailing Address - Fax:270-821-6580
Practice Address - Street 1:1102 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-3579
Practice Address - Country:US
Practice Address - Phone:270-707-1160
Practice Address - Fax:270-881-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9518Medicare ID - Type Unspecified
KY9693Medicare ID - Type Unspecified
KY9519Medicare ID - Type Unspecified