Provider Demographics
NPI:1205987542
Name:LILY CREEK MEDICAL GROUP, PSC
Entity type:Organization
Organization Name:LILY CREEK MEDICAL GROUP, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERTRAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:270-866-8881
Mailing Address - Street 1:PO BOX 5007
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40602-5007
Mailing Address - Country:US
Mailing Address - Phone:502-226-3858
Mailing Address - Fax:502-223-9829
Practice Address - Street 1:92 JOE T PETTY DR
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-8543
Practice Address - Country:US
Practice Address - Phone:270-866-8881
Practice Address - Fax:270-866-8849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000064586OtherANTHEM
KY608475500OtherBLACK LUNG
KY65932386Medicaid
KY65932386Medicaid