Basic Information
| Provider Information | |||||||||
| NPI: | 1265063580 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KING'S DAUGHTERS MEDICAL SPECIALTIES, INC. | ||||||||
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| OtherOrganizationName: | KINGS DAUGHTERS MEDICAL SPECIALTIES DERMATOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2379 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411052379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086612 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 CENTRAL AVE STE 4 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063241483 | ||||||||
| FaxNumber: | 6063292612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2020 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHITLATCH | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6064084401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207N00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.