Provider Demographics
NPI:1407993074
Name:LAKE CUMBERLAND GASTROENTEROLOGY AND INTERNAL MEDICINE ASSOC. INC.
Entity Type:Organization
Organization Name:LAKE CUMBERLAND GASTROENTEROLOGY AND INTERNAL MEDICINE ASSOC. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-679-7317
Mailing Address - Street 1:110 HARDIN LN
Mailing Address - Street 2:SUITE 9
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3818
Mailing Address - Country:US
Mailing Address - Phone:606-679-7317
Mailing Address - Fax:606-679-0139
Practice Address - Street 1:110 HARDIN LN
Practice Address - Street 2:SUITE 9
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3818
Practice Address - Country:US
Practice Address - Phone:606-679-7317
Practice Address - Fax:606-679-0139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RG0100X
KY363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3903Medicare PIN