Provider Demographics
NPI:1770024564
Name:CUMBERLAND FAMILY MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:CUMBERLAND FAMILY MEDICAL CENTER, INC.
Other - Org Name:LARUE COUNTY MIDDLE HEALTHY KIDS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-864-1472
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6644
Mailing Address - Fax:270-858-4027
Practice Address - Street 1:911 S LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:HODGENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42748-1701
Practice Address - Country:US
Practice Address - Phone:844-435-0900
Practice Address - Fax:270-858-4029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700172261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY700172OtherSTATE LICENSE
KY7100017280Medicaid