Provider Demographics
NPI:1982073813
Name:LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Entity Type:Organization
Organization Name:LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Other - Org Name:LAKE CUMBERLAND UROLOGY ASSOCIATES
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:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42502-0719
Mailing Address - Country:US
Mailing Address - Phone:606-451-0485
Mailing Address - Fax:606-451-0229
Practice Address - Street 1:30 MEDPARK SQUARE
Practice Address - Street 2:SUITE 1
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-1709
Practice Address - Country:US
Practice Address - Phone:606-451-0485
Practice Address - Fax:606-451-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-22
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty