Basic Information
| Provider Information | |||||||||
| NPI: | 1033167515 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CUMBERLAND ORTHOPAEDICS AND SPORTS MEDICINE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 LONDON MOUNTAIN VIEW DR | ||||||||
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| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407416601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068640770 | ||||||||
| FaxNumber: | 6068641461 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 LONDON MOUNTAIN VIEW DR | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407416601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068640770 | ||||||||
| FaxNumber: | 6068641461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 04/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | PAGE' | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6068640770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 213ES0103X | 00308 | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 207X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 65933327 | 05 | KY | MEDICAID | CB6337 | 01 | RAILROAD MEDICARE | OTHER | 164304800 | 01 | WORKERS COMPENSATION | OTHER | 7890447100 | 05 | KY | MEDICAID | 95901328 | 05 | KY | MEDICAID |