Basic Information
| Provider Information | |||||||||
| NPI: | 1437483815 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CUMBERLAND FAMILY MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | RUSSELL FAMILLLY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708641472 | ||||||||
| FaxNumber: | 2708641693 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 STEVE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELL SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426424622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708663161 | ||||||||
| FaxNumber: | 2708663163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2009 | ||||||||
| LastUpdateDate: | 03/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | LOY | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTICE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2708642889 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 7100017280 | 05 | KY | MEDICAID |