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General NPI Number Information
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NPI Number | 1255468872
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Entity Type | Organization
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Legal Business Name | EAST LOUISVILLE DERMATOLOGY, PSC
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4912 US HIGHWAY 42 SUITE 208
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City | LOUISVILLE
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State | KY
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Zip | 40222-6349
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Country | US
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Telephone | 502-426-9565
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Fax | 502-425-3240
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Provider Business Mailing Address
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Address Line | 4912 US HIGHWAY 42 SUITE 208
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City | LOUISVILLE
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State | KY
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Zip | 40222-6349
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Country | US
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Telephone | 502-426-9565
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Fax | 502-425-3240
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TERRIE S WILLIAMS
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Credential | M.D.
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Telephone | 502-426-9565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 24086
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License Number State | KY
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