Healthcare Provider Details

I. General information

NPI: 1598820078
Provider Name (Legal Business Name): CUMBERLAND OTOLARYNGOLOGY CONSULTANTS, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 BOGLE ST STE 3
SOMERSET KY
42503-2870
US

IV. Provider business mailing address

402 BOGLE ST STE 3
SOMERSET KY
42503-2870
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-7426
  • Fax: 606-679-7745
Mailing address:
  • Phone: 606-679-7426
  • Fax: 606-679-7745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN T KAVANAGH
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 606-679-7426