Basic Information
| Provider Information | |||||||||
| NPI: | 1437679990 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CUMBERLAND FOOT AND ANKLE CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 TRADEPARK DR STE B | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066792773 | ||||||||
| FaxNumber: | 6066794626 | ||||||||
| Practice Location | |||||||||
| Address1: | 1830 DESTINY LN STE 110 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421041088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708463338 | ||||||||
| FaxNumber: | 2708463318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2017 | ||||||||
| LastUpdateDate: | 06/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6066792773 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 213ES0103X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100207030 | 05 | KY | MEDICAID |