Healthcare Provider Details

I. General information

NPI: 1356526156
Provider Name (Legal Business Name): KRISTOPHER MICHAEL CUMBERMACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: K.C. CUMBERMACK M.D.

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE STREET MN 150 KENTUCKY CHILDREN'S HOSPITAL
LEXINGTON KY
40536-0298
US

IV. Provider business mailing address

800 ROSE STREET MN 150 KENTUCKY CHILDREN'S HOSPITAL
LEXINGTON KY
40536-0298
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5494
  • Fax: 859-323-3499
Mailing address:
  • Phone: 859-323-5494
  • Fax: 859-323-3499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number060362
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number44022
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: