Provider Demographics
NPI:1902928898
Name:LADIES CLINIC , PSC
Entity Type:Organization
Organization Name:LADIES CLINIC , PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-679-7353
Mailing Address - Street 1:347 BOGLE ST STE A
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2873
Mailing Address - Country:US
Mailing Address - Phone:606-679-7353
Mailing Address - Fax:
Practice Address - Street 1:347 BOGLE ST STE A
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2873
Practice Address - Country:US
Practice Address - Phone:606-679-7353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23151207VG0400X
KY1358P363LW0102X
KY5888P363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64231517Medicaid
KY7423OtherMEDICARE PTAN
KY64231517Medicaid
KY7423Medicare PIN