Healthcare Provider Details

I. General information

NPI: 1992528640
Provider Name (Legal Business Name): LAKE CUMBERLAND RHEUMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3897 CHARLESTOWN RD
NEW ALBANY IN
47150-9562
US

IV. Provider business mailing address

3897 CHARLESTOWN RD
NEW ALBANY IN
47150-9562
US

V. Phone/Fax

Practice location:
  • Phone: 502-495-3665
  • Fax: 502-874-5536
Mailing address:
  • Phone: 502-495-3665
  • Fax: 502-874-5536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: MR. MATT ROGERS
Title or Position: CEO
Credential: MHA
Phone: 502-495-3665