Basic Information
| Provider Information | |||||||||
| NPI: | 1831747146 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CUMBERLAND FAMILY MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | PINE KNOT PRIMARY HEALTHY KIDS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708586655 | ||||||||
| FaxNumber: | 2708584607 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 E HIGHWAY 2792 | ||||||||
| Address2: | |||||||||
| City: | PINE KNOT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426359159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444350900 | ||||||||
| FaxNumber: | 2706923559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2019 | ||||||||
| LastUpdateDate: | 02/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | LOY | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2708586655 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 7100017280 | 05 | KY | MEDICAID |