Provider Demographics
NPI:1518406859
Name:LAKE CUMBERLAND PEDIATRICS PLLC
Entity Type:Organization
Organization Name:LAKE CUMBERLAND PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:CLAY
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-753-0293
Mailing Address - Street 1:PO BOX 1737
Mailing Address - Street 2:N/A
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-4737
Mailing Address - Country:US
Mailing Address - Phone:606-753-0293
Mailing Address - Fax:606-753-0291
Practice Address - Street 1:268 ROLLING HILLS BLVD.
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-9004
Practice Address - Country:US
Practice Address - Phone:606-753-0293
Practice Address - Fax:606-753-0291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 208000000X, 363LF0000X
KY900327261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY900327OtherRHC LIC
KY18-8969OtherMEDICARE PART A
KY7100447120Medicaid
KY7100462460OtherNP GROUP MEDICAID