Healthcare Provider Details

I. General information

NPI: 1407993074
Provider Name (Legal Business Name): LAKE CUMBERLAND GASTROENTEROLOGY AND INTERNAL MEDICINE ASSOC. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HARDIN LN SUITE 9
SOMERSET KY
42503-3818
US

IV. Provider business mailing address

110 HARDIN LN SUITE 9
SOMERSET KY
42503-3818
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-7317
  • Fax: 606-679-0139
Mailing address:
  • Phone: 606-679-7317
  • Fax: 606-679-0139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateKY

VIII. Authorized Official

Name: MRS. BRENDA ROBACK
Title or Position: OFFICE MANAGER
Credential:
Phone: 606-679-7317