Provider Demographics
NPI:1720090525
Name:CPO PSC
Entity Type:Organization
Organization Name:CPO PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-366-0970
Mailing Address - Street 1:PO BOX 30563
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2057
Mailing Address - Country:US
Mailing Address - Phone:888-488-8289
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:4402 CHURCHMAN AVE
Practice Address - Street 2:SUITE 404
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1190
Practice Address - Country:US
Practice Address - Phone:502-363-4156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31716208VP0000X, 332B00000X
KY5222363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65900961Medicaid
KY78903531Medicaid
KY65900961Medicaid
KY6720860001Medicare NSC
KYCK4918Medicare PIN