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:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-444-8477
Mailing Address - Street 1:10 WALNUT SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:MO
Mailing Address - Zip Code:63341-2814
Mailing Address - Country:US
Mailing Address - Phone:636-219-6045
Mailing Address - Fax:
Practice Address - Street 1:127 ALBEN BARKLEY DR STE A
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-4402
Practice Address - Country:US
Practice Address - Phone:636-219-6045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical