Basic Information
| Provider Information | |||||||||
| NPI: | 1821130295 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OWENSBORO DERMATOLOGY ASSOCIATES, PSC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HENDERSON DERMATOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2821 NEW HARTFORD RD | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423031320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706855777 | ||||||||
| FaxNumber: | 2706850190 | ||||||||
| Practice Location | |||||||||
| Address1: | 2821 NEW HARTFORD RD | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423031320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706855777 | ||||||||
| FaxNumber: | 2706850190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GIRTEN | ||||||||
| AuthorizedOfficialFirstName: | JUNE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CLERICAL SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2706855777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 6592778200 | 05 | KY | MEDICAID |