Healthcare Provider Details

I. General information

NPI: 1801063698
Provider Name (Legal Business Name): LAKE CUMBERLAND SURGICAL CONSULTANTS PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HOSPITAL WAY STE 270
SOMERSET KY
42503-1875
US

IV. Provider business mailing address

350 HOSPITAL WAY STE 270
SOMERSET KY
42503-1875
US

V. Phone/Fax

Practice location:
  • Phone: 606-425-4298
  • Fax: 606-425-4299
Mailing address:
  • Phone: 606-425-4298
  • Fax: 606-425-4299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateKY

VIII. Authorized Official

Name: DR. TOMMY WARREN SHELTON
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 606-425-4298