Healthcare Provider Details

I. General information

NPI: 1780104281
Provider Name (Legal Business Name): CUMBERLAND FOOT AND ANKLE CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 06/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 TRADEPARK DR STE B
SOMERSET KY
42503-3427
US

IV. Provider business mailing address

117 TRADEPARK DR STE B
SOMERSET KY
42503-3428
US

V. Phone/Fax

Practice location:
  • Phone: 606-416-5225
  • Fax: 606-416-5386
Mailing address:
  • Phone: 606-679-2773
  • Fax: 606-679-4626

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 Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN E MOORE
Title or Position: ASSOCIATE PARTNER/PODIATRIST
Credential: DPM
Phone: 606-679-2773