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General NPI Number Information
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NPI Number | 1629497714
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Entity Type | Organization
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Legal Business Name | SKINMD
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Dates
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Enumeration Date | 04/16/2014
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Last Update Date | 07/16/2014
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Provider Practice Location Address
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Address Line | 989 GOVERNORS LN SUITE 220
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City | LEXINGTON
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State | KY
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Zip | 40513-1173
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Country | US
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Telephone | 859-296-7546
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Fax | 513-672-3323
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Provider Business Mailing Address
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Address Line | 200 NORTHLAND BLVD 1ST FLOOR
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City | CINCINNATI
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State | OH
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Zip | 45246-3604
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Country | US
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Telephone | 513-672-4111
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Fax | 513-672-4468
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Authorized Official
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Title or Position | PRESIDENT
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Name | SAMUEL PRUDEN
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Credential | MD
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Telephone | 859-276-7546
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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