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General NPI Number Information
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NPI Number | 1669539789
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Entity Type | Organization
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Legal Business Name | LOUISVILLE DERMATOLOGY ASC PSC
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Dates
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Enumeration Date | 01/02/2007
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Last Update Date | 12/02/2013
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Provider Practice Location Address
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Address Line | 1700 BLUEGRASS AVENUE SUITE 300
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City | LOUISVILLE
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State | KY
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Zip | 40215
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Country | US
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Telephone | 502-363-1841
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Fax | 502-366-3317
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Provider Business Mailing Address
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Address Line | 1700 BLUEGRASS AVENUE SUITE 300
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City | LOUISVILLE
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State | KY
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Zip | 40215
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Country | US
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Telephone | 502-363-1841
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Fax | 502-366-3317
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Authorized Official
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Title or Position | DERMATOLOGIST OWNER
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Name | MARTIN THOMAS LOGSDON
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Credential | MD
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Telephone | 502-363-1841
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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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 | 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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