Healthcare Provider Details

I. General information

NPI: 1720160526
Provider Name (Legal Business Name): CUMBERLAND GASTROENTEROLOGY, P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SOUTHCREEK DRIVE
MONTICELLO KY
42633
US

IV. Provider business mailing address

56 TOWER CIRCLE
SOMERSET KY
42503
US

V. Phone/Fax

Practice location:
  • Phone: 606-677-2913
  • Fax: 606-677-6983
Mailing address:
  • Phone: 606-677-2913
  • Fax: 606-677-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2617P
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number34871
License Number StateKY

VIII. Authorized Official

Name: SAMIR ISSA COOK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 606-677-2913