Provider Demographics
NPI:1558561696
Name:LAKE CUMBERLAND NEUROSURGICAL CLINIC
Entity Type:Organization
Organization Name:LAKE CUMBERLAND NEUROSURGICAL CLINIC
Other - Org Name:LAKE CUMBERLAND NEUROSURGICAL CLINIC - PA
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-678-9617
Mailing Address - Street 1:350 HOSPITAL WAY
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2872
Mailing Address - Country:US
Mailing Address - Phone:606-678-9617
Mailing Address - Fax:
Practice Address - Street 1:350 HOSPITAL WAY
Practice Address - Street 2:SUITE 270
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2872
Practice Address - Country:US
Practice Address - Phone:606-678-9617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty