Healthcare Provider Details

I. General information

NPI: 1982073813
Provider Name (Legal Business Name): LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MEDPARK SQUARE SUITE 1
SOMERSET KY
42503-1709
US

IV. Provider business mailing address

PO BOX 719
SOMERSET KY
42502-0719
US

V. Phone/Fax

Practice location:
  • Phone: 606-451-0485
  • Fax: 606-451-0229
Mailing address:
  • Phone: 606-451-0485
  • Fax: 606-451-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

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