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1871593996

NPI Code Detail

MEDICARE: SAMUEL J PRUDEN II MD

MEDICARE: SAMUEL J PRUDEN II MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0900X	Dermatopathology Physician	34192	KY
2	207Y00000X	Otolaryngology Physician	34192	KY
3	208200000X	Plastic Surgery Physician	34192	KY
4	207ND0101X	MOHS-Micrographic Surgery Physician	34192	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000823142	OTHER	KY	ANTHEM BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871593996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL J PRUDEN II MD

Provider Business Mailing Address
First Line	:	989 GOVERNORS LN STE 220
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40513-1175
Country	:	US
Telephone Number	:	859-296-7546
Fax Number	:	859-721-0829

Provider Business Practice Location Address
First Line	:	989 GOVERNORS LN STE 260
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40513-1175
Country	:	US
Telephone Number	:	859-296-7546
Fax Number	:	859-721-0829

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	12/15/2022

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Directions to “ SAMUEL J PRUDEN II MD” Practice Location

Language	Start Address	Practice Location

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