Provider Demographics
NPI:1730322181
Name:CUMBERLAND ORTHOPAEDIC & SPORTS MEDICINE-PODIATRY
Entity Type:Organization
Organization Name:CUMBERLAND ORTHOPAEDIC & SPORTS MEDICINE-PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PAGE'
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-864-0770
Mailing Address - Street 1:160 LONDON MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-6601
Mailing Address - Country:US
Mailing Address - Phone:606-864-0770
Mailing Address - Fax:606-864-1461
Practice Address - Street 1:160 LONDON MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-6601
Practice Address - Country:US
Practice Address - Phone:606-864-0770
Practice Address - Fax:606-864-1461
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CUMBERLAND ORTHOPAEDICS & SPORTS MEDICINE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-15
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00308213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100064080Medicaid