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General NPI Number Information
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NPI Number | 1407993074
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Entity Type | Organization
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Legal Business Name | LAKE CUMBERLAND GASTROENTEROLOGY AND INTERNAL MEDICINE ASSOC. INC.
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 06/21/2011
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Provider Practice Location Address
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Address Line | 110 HARDIN LN SUITE 9
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City | SOMERSET
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State | KY
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Zip | 42503-3818
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Country | US
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Telephone | 606-679-7317
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Fax | 606-679-0139
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Provider Business Mailing Address
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Address Line | 110 HARDIN LN SUITE 9
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City | SOMERSET
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State | KY
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Zip | 42503-3818
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Country | US
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Telephone | 606-679-7317
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Fax | 606-679-0139
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. BRENDA ROBACK
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Credential |
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Telephone | 606-679-7317
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State |
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