Healthcare Provider Details

I. General information

NPI: 1164832531
Provider Name (Legal Business Name): LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2014
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 JOE T PETTY DR
RUSSELL SPRINGS KY
42642-8533
US

IV. Provider business mailing address

PO BOX 719
SOMERSET KY
42502-0719
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-7771
  • Fax: 270-866-7774
Mailing address:
  • Phone: 270-866-7771
  • Fax: 270-866-7774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SARA MILLER
Title or Position: DIRECTOR
Credential:
Phone: 615-920-7514