Healthcare Provider Details

I. General information

NPI: 1932260783
Provider Name (Legal Business Name): BARDSTOWN DERMATOLOGY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 MANOR DR
BARDSTOWN KY
40004-3230
US

IV. Provider business mailing address

114 MANOR DR
BARDSTOWN KY
40004-3230
US

V. Phone/Fax

Practice location:
  • Phone: 502-349-9999
  • Fax: 502-349-9499
Mailing address:
  • Phone: 502-349-9999
  • Fax: 502-349-9499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. CONNIE CHESER
Title or Position: OFFICE MANAGER
Credential:
Phone: 502-349-9999