Healthcare Provider Details

I. General information

NPI: 1538594668
Provider Name (Legal Business Name): LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 BOGLE ST SUITE A
SOMERSET KY
42503-2895
US

IV. Provider business mailing address

PO BOX 719
SOMERSET KY
42502-0719
US

V. Phone/Fax

Practice location:
  • Phone: 606-451-6060
  • Fax: 606-678-4528
Mailing address:
  • Phone: 606-451-6060
  • Fax: 606-678-4528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: SARA MILLER
Title or Position: DIRECTOR
Credential:
Phone: 615-950-7514