Basic Information
| Provider Information | |||||||||
| NPI: | 1790092096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CUMBERLAND FOOT AND ANKLE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 TRADEPARK DR | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066792773 | ||||||||
| FaxNumber: | 6066794626 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 TREUHAFT BLVD | ||||||||
| Address2: | SUITE 3B | ||||||||
| City: | BARBOURVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409060000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066792773 | ||||||||
| FaxNumber: | 6066794626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2010 | ||||||||
| LastUpdateDate: | 09/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PODIATRIST | ||||||||
| 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 | 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 |