Provider Demographics
NPI:1790924785
Name:LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Entity Type:Organization
Organization Name:LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Other - Org Name:EAR NOSE & THROAT SPECIALIST OF SOUTH CENTRAL KENTUCKY
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 1:143A BOGLE OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2810
Mailing Address - Country:US
Mailing Address - Phone:606-451-3890
Mailing Address - Fax:606-451-3896
Practice Address - Street 1:143A BOGLE OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2810
Practice Address - Country:US
Practice Address - Phone:606-451-3890
Practice Address - Fax:606-451-3896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00971Medicare PIN