Provider Demographics
NPI:1417214669
Name:LAKE CUMBERLAND PHYSICIAN PRACTICES
Entity Type:Organization
Organization Name:LAKE CUMBERLAND PHYSICIAN PRACTICES
Other - Org Name:LAKE CUMBERLAND WEIGHT LOSS PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42502-0719
Mailing Address - Country:US
Mailing Address - Phone:606-425-4695
Mailing Address - Fax:606-425-4696
Practice Address - Street 1:154 BOGLE OFFICE PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2810
Practice Address - Country:US
Practice Address - Phone:606-425-4695
Practice Address - Fax:606-425-4696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty