Basic Information
| Provider Information | |||||||||
| NPI: | 1053550046 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC | ||||||||
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| OtherOrganizationName: | CARDIOTHORACIC SURGICAL ASSOCIATES OF LAKE CUMBERLAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 TRADEPARK DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425033454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064510300 | ||||||||
| FaxNumber: | 6064510595 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 TRADEPARK DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425033454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064510300 | ||||||||
| FaxNumber: | 6064510595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2009 | ||||||||
| LastUpdateDate: | 09/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | SARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6159207514 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 208G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.