Healthcare Provider Details

I. General information

NPI: 1326203142
Provider Name (Legal Business Name): DERMATOLOGY OF SOUTHERN KENTUCKY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 TOWER CIR
SOMERSET KY
42503-3476
US

IV. Provider business mailing address

85 TOWER CIR
SOMERSET KY
42503-3476
US

V. Phone/Fax

Practice location:
  • Phone: 606-772-3376
  • Fax: 606-677-0335
Mailing address:
  • Phone: 606-772-3376
  • Fax: 606-677-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number39921
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5583P
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1591
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number39921
License Number StateKY

VIII. Authorized Official

Name: DR. BRIAN L BAKER
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 606-772-3376