Basic Information
| Provider Information | |||||||||
| NPI: | 1205987542 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LILY CREEK MEDICAL GROUP, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5007 | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 406025007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022263858 | ||||||||
| FaxNumber: | 5022239829 | ||||||||
| Practice Location | |||||||||
| Address1: | 92 JOE T PETTY DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELL SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426428543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708668881 | ||||||||
| FaxNumber: | 2708668849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 10/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | BERTRAM | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2708668881 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000064586 | 01 | KY | ANTHEM | OTHER | 608475500 | 01 | KY | BLACK LUNG | OTHER | 65932386 | 05 | KY | MEDICAID |