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General NPI Number Information
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NPI Number | 1770806424
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Entity Type | Organization
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Legal Business Name | KENTUCKY DERMATOLOGY CLINIC, PLLC
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Dates
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Enumeration Date | 03/09/2010
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Last Update Date | 06/26/2012
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Provider Practice Location Address
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Address Line | 120 STATE AVE
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City | GLASGOW
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State | KY
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Zip | 42141-1451
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Country | US
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Telephone | 917-371-7230
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Fax | 636-444-2042
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Provider Business Mailing Address
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Address Line | 5480 WISCONSIN AVE #920
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City | CHEVY CHASE
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State | MD
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Zip | 20815-3530
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Country | US
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Telephone | 917-371-7230
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Fax | 636-444-2042
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Authorized Official
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Title or Position | CEO
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Name | CLEMENS ESCHE
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Credential | M.D.
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Telephone | 917-371-7230
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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 | 43075
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License Number State | KY
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