Provider Demographics
NPI:1700198884
Name:LAKE CUMBERLAND PHYSICIAN PRACTICES LLC
Entity Type:Organization
Organization Name:LAKE CUMBERLAND PHYSICIAN PRACTICES LLC
Other - Org Name:SPORTS MEDICINE AND ORTHOPAEDIC CENTER OF LAKE CUMBERLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7514
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027
Mailing Address - Country:US
Mailing Address - Phone:615-920-7780
Mailing Address - Fax:615-920-8775
Practice Address - Street 1:353 BOGLE ST
Practice Address - Street 2:SUITE C
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2888
Practice Address - Country:US
Practice Address - Phone:606-678-2220
Practice Address - Fax:606-451-0595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100136480Medicaid
KYP100022773Medicare PIN