Organization
FACIAL PLASTIC SURGERY & DERMATOLOGY PLLC
Active
Organization
FACIAL PLASTIC SURGERY & DERMATOLOGY PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SAMUEL JACK PRUDEN II MD (OWNER)
(859) 226-0206
Entity
Organization
Contact information
Practice address
448 LEWIS HARGETT CIR, STE 240, LEXINGTON, KY 40503-3594
(859) 226-0206
(859) 226-0207
Mailing address
3070 LAKECREST CIR, STE. 400-264, LEXINGTON, KY 40513-1937
(859) 226-0206
(859) 226-0207
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
34192
KY
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
34192
KY
208200000X
Plastic Surgery Physician
34192
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000823139
ANTHEM BCBS
KY
05
—
7100245900
—
KY
Enumeration date
05/14/2013
Last updated
08/27/2013
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