Provider Demographics
NPI:1558695262
Name:LAKE CUMBERLAND CARDIOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:LAKE CUMBERLAND CARDIOLOGY ASSOCIATES, LLC
Other - Org Name:LAKE CUMBERLAND CARDIOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:120 TRADEPARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3454
Mailing Address - Country:US
Mailing Address - Phone:606-678-0599
Mailing Address - Fax:606-678-0608
Practice Address - Street 1:50 MEDPARK SQUARE
Practice Address - Street 2:STE 1
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503
Practice Address - Country:US
Practice Address - Phone:606-678-0599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100108260Medicaid
KY7100108260Medicaid