Provider Demographics
NPI:1295823698
Name:CUMBERLAND GASTROENTEROLOGY, P.S.C.
Entity Type:Organization
Organization Name:CUMBERLAND GASTROENTEROLOGY, P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:ISSA
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-677-2913
Mailing Address - Street 1:56 TOWER CIR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3476
Mailing Address - Country:US
Mailing Address - Phone:606-677-2913
Mailing Address - Fax:606-677-6983
Practice Address - Street 1:56 TOWER CIR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3476
Practice Address - Country:US
Practice Address - Phone:606-677-2913
Practice Address - Fax:606-677-6983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34871207RG0100X
KY4617P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100161540OtherKY MEDICAID NP GROUP
KY65933517Medicaid
KY5851Medicare ID - Type UnspecifiedGROUP
KY7100161540OtherKY MEDICAID NP GROUP