Provider Demographics
NPI:1801063698
Name:LAKE CUMBERLAND SURGICAL CONSULTANTS PSC
Entity type:Organization
Organization Name:LAKE CUMBERLAND SURGICAL CONSULTANTS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-425-4298
Mailing Address - Street 1:350 HOSPITAL WAY STE 270
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-1875
Mailing Address - Country:US
Mailing Address - Phone:606-425-4298
Mailing Address - Fax:606-425-4299
Practice Address - Street 1:350 HOSPITAL WAY STE 270
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-1875
Practice Address - Country:US
Practice Address - Phone:606-425-4298
Practice Address - Fax:606-425-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY363AS0400X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100052880 - MD GRPMedicaid
KY00675Medicare PIN