Provider Demographics
NPI:1689848525
Name:CORBIN LONDON MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:CORBIN LONDON MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-528-0305
Mailing Address - Street 1:1007 CUMBERLAND FALLS HWY
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701
Mailing Address - Country:US
Mailing Address - Phone:606-528-0305
Mailing Address - Fax:606-523-4368
Practice Address - Street 1:1007 CUMBERLAND FALLS HWY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701
Practice Address - Country:US
Practice Address - Phone:606-528-0305
Practice Address - Fax:606-523-4368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1033143207Q00000X
KY1086037207Q00000X
KY39404207R00000X
KY002008208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP92279Medicare UPIN
KYI49810Medicare UPIN
KY6298310001Medicare NSC
Q19694Medicare UPIN