=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124441274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2014
-----------------------------------------------------
Last Update Date | 02/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 BOGLE ST SUITE 101
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42503-3823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-676-0275
-----------------------------------------------------
Fax | 606-676-0295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 719
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42502-0719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-676-0275
-----------------------------------------------------
Fax | 606-676-0295
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MONICA BOWMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 159-207-0006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------