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General NPI Number Information
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NPI Number | 1881030088
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Entity Type | Organization
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Legal Business Name | FACIAL PLASTIC SURGERY & DERMATOLOGY PLLC
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Dates
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Enumeration Date | 05/14/2013
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Last Update Date | 08/27/2013
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Provider Practice Location Address
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Address Line | 448 LEWIS HARGETT CIR STE 240
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City | LEXINGTON
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State | KY
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Zip | 40503-3594
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Country | US
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Telephone | 859-226-0206
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Fax | 859-226-0207
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Provider Business Mailing Address
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Address Line | 3070 LAKECREST CIR STE. 400-264
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City | LEXINGTON
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State | KY
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Zip | 40513-1937
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Country | US
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Telephone | 859-226-0206
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Fax | 859-226-0207
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Authorized Official
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Title or Position | OWNER
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Name | SAMUEL JACK PRUDEN II
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Credential | MD
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Telephone | 859-226-0206
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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 | 34192
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 34192
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License Number State | KY
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Taxonomy #3
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 34192
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License Number State | KY
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