Healthcare Provider Details

I. General information

NPI: 1912720665
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

101 PROSPEROUS PL STE 350
LEXINGTON KY
40509-1891
US

IV. Provider business mailing address

101 PROSPEROUS PL STE 350
LEXINGTON KY
40509-1891
US

V. Phone/Fax

Practice location:
  • Phone: 859-654-0160
  • Fax: 859-712-9273
Mailing address:
  • Phone: 859-654-0160
  • Fax: 859-712-9273

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