Healthcare Provider Details

I. General information

NPI: 1831310390
Provider Name (Legal Business Name): KENTUCKY DERMATOLOGY AND SKIN CANCER CLINIC, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 BURT RD
LEXINGTON KY
40503-2410
US

IV. Provider business mailing address

177 BURT RD
LEXINGTON KY
40503-2410
US

V. Phone/Fax

Practice location:
  • Phone: 859-276-1511
  • Fax: 859-276-3373
Mailing address:
  • Phone: 859-276-1511
  • Fax: 859-276-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: KAYE FENSTERMAKER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 859-276-1511