Healthcare Provider Details

I. General information

NPI: 1578600367
Provider Name (Legal Business Name): LAKE CUMBERLAND WOMENS HEALTH SPECIALISTS,PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 BOGLE ST
SOMERSET KY
42503-2873
US

IV. Provider business mailing address

333 BOGLE ST
SOMERSET KY
42503-2873
US

V. Phone/Fax

Practice location:
  • Phone: 606-678-0705
  • Fax: 606-678-2807
Mailing address:
  • Phone: 606-678-0705
  • Fax: 606-678-2807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number StateKY

VIII. Authorized Official

Name: DR. DALE EDWARD RUTLEDGE I
Title or Position: PHYSICIAN VP
Credential: M.D.
Phone: 606-678-0705