Healthcare Provider Details

I. General information

NPI: 1124441274
Provider Name (Legal Business Name): LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BOGLE ST SUITE 101
SOMERSET KY
42503-3823
US

IV. Provider business mailing address

PO BOX 719
SOMERSET KY
42502-0719
US

V. Phone/Fax

Practice location:
  • Phone: 606-676-0275
  • Fax: 606-676-0295
Mailing address:
  • Phone: 606-676-0275
  • Fax: 606-676-0295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MONICA BOWMAN
Title or Position: DIRECTOR
Credential:
Phone: 159-207-0006