Healthcare Provider Details

I. General information

NPI: 1386999027
Provider Name (Legal Business Name): LAKE CUMBERLAND PHYSICIAN PRACTICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 BOGLE OFFICE PARK DR SUITE B
SOMERSET KY
42503
US

IV. Provider business mailing address

154 BOGLE OFFICE PARK DR SUITE B
SOMERSET KY
42503-2810
US

V. Phone/Fax

Practice location:
  • Phone: 606-451-3958
  • Fax:
Mailing address:
  • Phone: 606-451-3958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHY TEAGUE
Title or Position: DIRECTOR
Credential:
Phone: 615-920-7000