Healthcare Provider Details

I. General information

NPI: 1639264401
Provider Name (Legal Business Name): DERMATOLOGY & SKIN SURGERY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MEDICAL CENTER DR
PADUCAH KY
42003-7909
US

IV. Provider business mailing address

110 MEDICAL CENTER DR
PADUCAH KY
42003-7909
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-2471
  • Fax: 270-443-5808
Mailing address:
  • Phone: 270-443-2471
  • Fax: 270-443-5808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. JEANNIE HUGHES
Title or Position: OFFICE MANAGER
Credential:
Phone: 270-443-2471