Provider Demographics
NPI:1053819904
Name:CUMBERLAND FOOT AND ANKLE CENTERS
Entity Type:Organization
Organization Name:CUMBERLAND FOOT AND ANKLE CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:606-679-2773
Mailing Address - Street 1:117 TRADEPARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3428
Mailing Address - Country:US
Mailing Address - Phone:606-679-2773
Mailing Address - Fax:606-679-4626
Practice Address - Street 1:1850 WESTEN STREET
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104
Practice Address - Country:US
Practice Address - Phone:270-846-3338
Practice Address - Fax:270-846-3318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100207030Medicaid
KY7100234690Medicaid