Provider Demographics
NPI:1366564494
Name:SKIN GROUP PLLC
Entity type:Organization
Organization Name:SKIN GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:ZAX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-583-6647
Mailing Address - Street 1:PO BOX 36422
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40233-6422
Mailing Address - Country:US
Mailing Address - Phone:502-583-6647
Mailing Address - Fax:
Practice Address - Street 1:2307 RIVER RD STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-5000
Practice Address - Country:US
Practice Address - Phone:502-583-6647
Practice Address - Fax:502-585-4824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1034363A00000X
KY4440P363L00000X
KY25359207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78904968Medicaid
KY18D0934789OtherCLIA NUMBER
KY65938797Medicaid
KYDA0326OtherRR MCR
KY18D0934789OtherCLIA NUMBER