Provider Demographics
NPI:1720143779
Name:LAKE CUMBERLAND SURGERY CENTER LP
Entity Type:Organization
Organization Name:LAKE CUMBERLAND SURGERY CENTER LP
Other - Org Name:LAKE CUMBERLAND SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-7220
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4536
Mailing Address - Country:US
Mailing Address - Phone:615-920-7000
Mailing Address - Fax:615-920-8913
Practice Address - Street 1:301 LANGDON ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2750
Practice Address - Country:US
Practice Address - Phone:606-678-9688
Practice Address - Fax:606-679-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY300141261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY36001246Medicaid
KY000000288161OtherBCBS
KYP00000869OtherRAILROAD MEDICARE ASC
KYASC1034Medicare ID - Type UnspecifiedAMBULATORY SURGERY