Healthcare Provider Details

I. General information

NPI: 1205987542
Provider Name (Legal Business Name): LILY CREEK MEDICAL GROUP, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 10/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 JOE T PETTY DR
RUSSELL SPRINGS KY
42642-8543
US

IV. Provider business mailing address

PO BOX 5007
FRANKFORT KY
40602-5007
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-8881
  • Fax: 270-866-8849
Mailing address:
  • Phone: 502-226-3858
  • Fax: 502-223-9829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT L. BERTRAM
Title or Position: PRESIDENT
Credential: D.O.
Phone: 270-866-8881