Healthcare Provider Details

I. General information

NPI: 1699382507
Provider Name (Legal Business Name): MODERN DERMATOLOGY OF KENTUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 LEXINGTON GREEN CIR STE 100
LEXINGTON KY
40503-3801
US

IV. Provider business mailing address

169 BURT RD
LEXINGTON KY
40503-2455
US

V. Phone/Fax

Practice location:
  • Phone: 859-276-1511
  • Fax: 859-277-2556
Mailing address:
  • Phone: 859-278-9242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: FRANK COMBS
Title or Position: MANAGING PARTNER
Credential:
Phone: 859-276-1511