Healthcare Provider Details

I. General information

NPI: 1104261403
Provider Name (Legal Business Name): LAKE CUMBERLAND PHYSICIAN PRACTICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 BOGLE ST SUITE B
SOMERSET KY
42503-2888
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027
US

V. Phone/Fax

Practice location:
  • Phone: 606-678-2663
  • Fax: 606-678-0576
Mailing address:
  • Phone: 615-920-7000
  • Fax: 615-920-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

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