Provider Demographics
NPI:1053550046
Name:LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Entity type:Organization
Organization Name:LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7514
Mailing Address - Street 1:120 TRADEPARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3454
Mailing Address - Country:US
Mailing Address - Phone:606-451-0300
Mailing Address - Fax:606-451-0595
Practice Address - Street 1:120 TRADEPARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3454
Practice Address - Country:US
Practice Address - Phone:606-451-0300
Practice Address - Fax:606-451-0595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00979Medicare PIN