Healthcare Provider Details

I. General information

NPI: 1689848525
Provider Name (Legal Business Name): CORBIN LONDON MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 07/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 CUMBERLAND FALLS HWY
CORBIN KY
40701
US

IV. Provider business mailing address

1007 CUMBERLAND FALLS HWY
CORBIN KY
40701
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-0305
  • Fax: 606-523-4368
Mailing address:
  • Phone: 606-528-0305
  • Fax: 606-523-4368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1086037
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number39404
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number002008
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1033143
License Number StateKY

VIII. Authorized Official

Name: DR. JONATHAN E. MOORE
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 606-528-0305