Basic Information
Provider Information | |||||||||
NPI: | 1467768747 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CUMBERLAND FOOT AND ANKLE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 117 TRADEPARK DR | ||||||||
Address2: |   | ||||||||
City: | SOMERSET | ||||||||
State: | KY | ||||||||
PostalCode: | 425033428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6066792773 | ||||||||
FaxNumber: | 6066794626 | ||||||||
Practice Location | |||||||||
Address1: | 475 N HIGHWAY 25 W | ||||||||
Address2: | SUITE 101 | ||||||||
City: | WILLIAMSBURG | ||||||||
State: | KY | ||||||||
PostalCode: | 407691576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6066792773 | ||||||||
FaxNumber: | 6066794626 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2010 | ||||||||
LastUpdateDate: | 08/25/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOORE | ||||||||
AuthorizedOfficialFirstName: | JONATHAN | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PODIATRIST | ||||||||
AuthorizedOfficialTelephone: | 6066792773 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 90005091 | 05 | KY |   | MEDICAID |