Provider Demographics
NPI:1073029047
Name:CUMBERLAND FAMILY MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:CUMBERLAND FAMILY MEDICAL CENTER, INC
Other - Org Name:FIRST CHOICE IMMEDIATE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-858-6655
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:360 KEEN STREET
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6655
Mailing Address - Fax:270-858-4026
Practice Address - Street 1:197 WILL WALKER ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728
Practice Address - Country:US
Practice Address - Phone:270-384-9981
Practice Address - Fax:270-384-9989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700172261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100017280Medicaid