Provider Demographics
NPI:1619073319
Name:BASCOM, CHERYL LUCY (MD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LUCY
Last Name:BASCOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:613 23RD ST
Practice Address - Street 2:STE. 350
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2878
Practice Address - Country:US
Practice Address - Phone:606-408-8200
Practice Address - Fax:606-408-6291
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38583207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64093370Medicaid
000000345909OtherANTHEM INSURANCE
WV3810028923Medicaid
OH2549148Medicaid
I17790Medicare UPIN
000000345909OtherANTHEM INSURANCE