Healthcare Provider Details

I. General information

NPI: 1053301788
Provider Name (Legal Business Name): CUMBERLAND CARDIOLOGY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 23RD ST STE 230
ASHLAND KY
41101-2876
US

IV. Provider business mailing address

PO BOX 2380
ASHLAND KY
41105-2380
US

V. Phone/Fax

Practice location:
  • Phone: 606-324-4745
  • Fax: 606-326-0165
Mailing address:
  • Phone: 606-324-4745
  • Fax: 606-326-0165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA682
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD E PAULUS
Title or Position: PRESIDENT
Credential: MD
Phone: 606-324-4743