Provider Demographics
NPI:1528375821
Name:CUMBERLAND FOOT AND ANKLE CENTER
Entity Type:Organization
Organization Name:CUMBERLAND FOOT AND ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:606-679-2773
Mailing Address - Street 1:117 TRADEPARK DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3428
Mailing Address - Country:US
Mailing Address - Phone:606-679-2773
Mailing Address - Fax:606-679-4626
Practice Address - Street 1:49 MEDICAL LOOP
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653-0000
Practice Address - Country:US
Practice Address - Phone:606-376-2272
Practice Address - Fax:606-376-2461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90005091Medicaid
KY4538530001Medicare NSC