Provider Demographics
NPI:1548770076
Name:CUMBERLAND FAMILY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:CUMBERLAND FAMILY MEDICAL CENTER INC
Other - Org Name:ALBANY FAMILY MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:AMONETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-864-1472
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-864-1472
Mailing Address - Fax:270-864-1693
Practice Address - Street 1:127 FOOTHILLS AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:KY
Practice Address - Zip Code:42602-1037
Practice Address - Country:US
Practice Address - Phone:606-387-0047
Practice Address - Fax:606-387-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700172261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100017280Medicaid